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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
2933665
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
02
02/11/2021
02/11/2021
02/12/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
60
100.00000
Replenished
1001811232
987509357
False
3080831
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
03
03/12/2021
03/12/2021
03/13/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
8
13.33300
Replenished
1001825961
3049810903
False
3087799
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
03
03/12/2021
03/12/2021
03/13/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
52
86.66700
Replenished
1001826768
3050065355
False
3440622
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
04
04/28/2021
04/28/2021
04/29/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
22
36.66700
Replenished
1001850290
3054303928
False
3447151
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
04
04/28/2021
04/28/2021
04/29/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
38
63.33300
Replenished
1001863873
3056827846
False
3622362
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
05
05/24/2021
05/24/2021
05/25/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
6
10.00000
Replenished
1001863873
3056827846
False
3625907
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011117
MR00202849
05
05/24/2021
05/24/2021
05/25/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
54
90.00000
Replenished
1001865893
3057164795
False
2967680
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011238
MR00177844
00
01/29/2021
01/29/2021
02/20/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
56
56
100.00000
Replenished
1001825961
3049810903
False
2933666
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011246
MR00152715
00
02/05/2021
02/05/2021
02/06/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
4
4.44400
Replenished
1001807887
False
2933667
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011246
MR00152715
00
02/05/2021
02/05/2021
02/06/2021
00093321201
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
40
44.44400
Replenished
1001811232
987509357