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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	2934591		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776861	MR00310337	00	10/03/2020	10/03/2020	10/04/2020	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	56	23	41.07100	Replenished		1001899045	3063437222
False	2934590		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776861	MR00310337	00	10/03/2020	10/03/2020	10/04/2020	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	56	33	58.92900	Replenished		1001741330
False	2934589		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779402	MR00112843	00	01/25/2021	01/25/2021	01/26/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	4	4	100.00000	Replenished		1001899045	3063437222
False	3006955		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780193	MR00024743	00	02/26/2021	02/26/2021	02/28/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	4	4	100.00000	Replenished		1001899045	3063437222
False	3440631		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781558	MR00158455	00	04/28/2021	04/28/2021	04/29/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	4	4	100.00000	Replenished		1001899045	3063437222
False	3485902		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781725	MR00388862	00	05/05/2021	05/05/2021	05/06/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	30	30	100.00000	Replenished		1001899045	3063437222
False	3678010		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782375	MR00134075	00	06/02/2021	06/02/2021	06/03/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	9	9	100.00000	Replenished		1001899045	3063437222
False	3729043		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782546	MR00195562	00	06/09/2021	06/09/2021	06/10/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	12	12	100.00000	Replenished		1001899045	3063437222
False	4113017		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783528	MR00112843	00	07/23/2021	07/23/2021	07/24/2021	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	4	4	100.00000	Replenished		1001899045	3063437222
False	6945775		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783528	MR00112843	01	07/23/2022	07/23/2022	07/24/2022	00781261301	AMOXICILLIN 500 MG CAPSULE	500 MG	CAPSULE	100	4	4	100.00000	Replenished		1002109182	3106682332