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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
8765209
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000793356
MR00209146
05
03/06/2023
03/06/2023
03/06/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
30
30
100.00000
Replenished
1002185583
3125815325
False
8765208
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000795742
MR00036918
01
03/06/2023
03/06/2023
03/06/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
30
30
100.00000
Replenished
1002185583
3125815325
False
8759358
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796264
MR00074500
00
02/24/2023
02/24/2023
03/06/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1002185321
3125655997
False
8761019
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796264
MR00074500
00
02/24/2023
02/24/2023
03/06/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1002185321
3125655997
False
8761020
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796264
MR00074500
00
02/24/2023
02/24/2023
03/06/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33400
Replenished
1002185321
3125655997
False
8682313
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000795816
MR00182534
01
02/25/2023
02/25/2023
02/25/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
30
30
100.00000
Replenished
1002182991
3124681387
False
8682302
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000795879
MR00200984
01
02/25/2023
02/25/2023
02/25/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
30
30
100.00000
Replenished
1002182991
3124681387
False
8669236
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000796330
MR00324885
00
02/24/2023
02/24/2023
02/24/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1002182751
3124681385
False
8676803
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000796330
MR00324885
00
02/24/2023
02/24/2023
02/24/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1002182751
3124681385
False
8676804
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000796330
MR00324885
00
02/24/2023
02/24/2023
02/24/2023
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33400
Replenished
1002182751
3124681385