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Accumulator - View By Claim

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Health Center:

Pharmacy:

Capture Date :

To:

			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	2934286		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777035	MR00281435	04	02/11/2021	02/11/2021	02/12/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	2934288		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778683	MR00259169	01	02/02/2021	02/02/2021	02/03/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	2934287		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779723	MR00174245	00	02/08/2021	02/08/2021	02/09/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	2979696		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779347	MR00046140	01	02/23/2021	02/23/2021	02/24/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001819373	988099025
False	2934289		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779608	MR00171522	00	02/02/2021	02/02/2021	02/03/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001819373	988099025
False	3020624		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780261	MR00171522	00	03/01/2021	03/01/2021	03/02/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001819373	988099025
False	3071212		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777035	MR00281435	05	03/10/2021	03/10/2021	03/11/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001829639	3050481250
False	3145663		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778676	MR00279837	01	03/20/2021	03/20/2021	03/21/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	90	30	33.33300	Replenished		1001829639	3050481250
False	3080841		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780498	MR00259169	00	03/12/2021	03/12/2021	03/13/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	30	30	100.00000	Replenished		1001829639	3050481250
False	3149077		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778676	MR00279837	01	03/20/2021	03/20/2021	03/21/2021	00527328046	LEVOTHYROXINE 25 MCG TABLET	25 MCG	TABLET	90	90	60	66.66700	Replenished		1001831820	3050993427