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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
5944856
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789191
MR00043501
00
03/25/2022
03/25/2022
03/26/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002045985
3091824990
False
6232281
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789942
MR00043501
00
05/02/2022
05/02/2022
05/03/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
20
33.33300
Replenished
1002075849
3098184654
False
6224710
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789942
MR00043501
00
05/02/2022
05/02/2022
05/03/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
40
66.66700
Replenished
1002045985
3091824990
False
6395786
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000790462
MR00043501
00
05/25/2022
05/25/2022
05/26/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002075849
3098184654
False
6782460
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000791259
MR00043501
00
07/01/2022
07/01/2022
07/02/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
20
33.33300
Replenished
1002075849
3098184654
False
6790449
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000791259
MR00043501
00
07/01/2022
07/01/2022
07/02/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
40
66.66700
Replenished
1002085352
3101083317
False
6987275
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000791836
MR00043501
00
07/28/2022
07/28/2022
07/29/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002085352
3101083317
False
7455715
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000793201
MR00043501
00
09/30/2022
09/30/2022
10/01/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
20
33.33300
Replenished
1002142782
3114755273
False
7450351
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000793201
MR00043501
00
09/30/2022
09/30/2022
10/01/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
40
66.66700
Replenished
1002113582
3107872087
False
7960388
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794587
MR00043501
00
12/01/2022
12/01/2022
12/03/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
20
33.33300
Replenished
1002142782
3114755273