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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
8925045
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012615
MR00154246
00
03/24/2023
03/24/2023
03/25/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
28
28
100.00000
Replenished
05/26/2023
1002223394
3134652723
False
9181919
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012647
MR00154246
00
04/21/2023
04/21/2023
04/22/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
56
56
100.00000
Replenished
05/26/2023
1002223394
3134652723
False
9470425
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012699
MR00071187
00
05/23/2023
05/23/2023
05/24/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
60
6
10.00000
Replenished
05/26/2023
1002223394
3134652723
False
9475914
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012699
MR00071187
00
05/23/2023
05/23/2023
05/24/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
60
20
33.33300
Replenished
08/22/2023
1002251495
3141657236
False
9475913
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012699
MR00071187
00
05/23/2023
05/23/2023
05/24/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
60
34
56.66700
Replenished
05/26/2023
1002223394
3134652723
False
9470443
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012703
MR00154246
00
05/24/2023
05/24/2023
05/25/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
56
56
100.00000
Replenished
05/26/2023
1002223394
3134652723
False
9825576
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012761
MR00154246
00
06/30/2023
06/30/2023
07/01/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
56
56
100.00000
Replenished
08/22/2023
1002251495
3141657236
False
10028375
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012796
MR00154246
00
07/27/2023
07/27/2023
07/28/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
56
14
25.00000
Replenished
08/22/2023
1002251495
3141657236
False
10033533
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012796
MR00154246
00
07/27/2023
07/27/2023
07/28/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
56
42
75.00000
Replenished
08/24/2023
1002262221
3144548021
False
10132256
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012818
MR00389502
00
08/11/2023
08/11/2023
08/12/2023
69097067705
PREGABALIN 25 MG CAPSULE
25 MG
CAPSULE
90
30
30
100.00000
Replenished
08/24/2023
1002262221
3144548021