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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	8156698		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012500	MR00062075	00	12/27/2022	12/27/2022	12/28/2022	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	120	100	83.33300	Replenished		1002154521	3117768445
False	8332396		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	00	01/16/2023	01/16/2023	01/17/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	100	74.07400	Replenished		1002164575	3120074503
False	8885328		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	02	03/20/2023	03/20/2023	03/21/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	100	74.07400	Replenished		1002193992	3127402542
False	8721916		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012580	MR00062075	00	02/28/2023	02/28/2023	03/01/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	120	99	82.50000	Replenished		1002184466	3125496600
False	9490161		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	04	05/25/2023	05/25/2023	05/26/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	92	68.14800	Replenished	06/05/2023	1002226246	3135522745
False	8156724		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012502	MR00076060	00	12/27/2022	12/27/2022	12/28/2022	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	90	90	100.00000	Replenished		1002154521	3117768445
False	8240987		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012517	MR00389170	00	01/05/2023	01/05/2023	01/06/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	105	90	85.71400	Replenished		1002160851	3118886766
False	8412365		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012538	MR00062075	00	01/25/2023	01/25/2023	01/26/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	120	90	75.00000	Replenished		1002168592	3121399109
False	9544271		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012711	MR00076060	00	05/30/2023	05/30/2023	06/01/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	90	90	100.00000	Replenished	06/05/2023	1002226246	3135522745
False	8652351		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	01	02/20/2023	02/22/2023	02/23/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	89	65.92600	Replenished		1002182991	3124681386