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Health Center:
Memorial Hospital
Pharmacy:
Trapp Pharmacy (#1)
Capture Date :
To:
Fetching results...
Health
Center
Pharmacy
ShipTo
Claim
Type
RX
Number
Member ID
Fill
Fill Date
Adjud
Date
Captured
Date
NDC
Drug
Name
Strength
Form
Pkg
Size
QTY
Disp
Curr
QTY
% of
Claim
Status
Status
Date
Order
Wholesaler
Invoice
False
4214266
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777049
MR00283017
03
08/06/2021
08/06/2021
08/07/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
90
30
33.33300
Replenished
1001900472
3063887831
False
4219143
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777049
MR00283017
03
08/06/2021
08/06/2021
08/07/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
90
30
33.33300
Replenished
1001900472
3063887831
False
4219144
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777049
MR00283017
03
08/06/2021
08/06/2021
08/07/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
90
30
33.33400
Replenished
1001900472
3063887831
False
4207165
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000778438
MR00202849
08
08/05/2021
08/05/2021
08/06/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
30
30
100.00000
Replenished
1001899897
3063887299
False
4228208
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000783244
MR00373597
01
08/09/2021
08/09/2021
08/10/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
30
30
100.00000
Replenished
1001902393
3064140711
False
4221182
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000783849
MR00223918
00
08/06/2021
08/06/2021
08/08/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
90
30
33.33300
Replenished
1001900773
3063887832
False
4225020
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000783849
MR00223918
00
08/06/2021
08/06/2021
08/08/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
90
30
33.33300
Replenished
1001900773
3063887832
False
4225021
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000783849
MR00223918
00
08/06/2021
08/06/2021
08/08/2021
68462039630
OMEPRAZOLE DR 20 MG CAPSULE
20 MG
CAPSULE DR
30
90
30
33.33400
Replenished
1001900773
3063887832