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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	8728051		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012584	MR00313919	00	03/02/2023	03/02/2023	03/03/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	20	1	5.00000	Replenished		1002184466	3125496600
False	9051440		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012631	MR00108692	00	04/06/2023	04/06/2023	04/07/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	7	23.33300	Replenished		1001765592
False	9397900		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012678	MR00192351	00	05/09/2023	05/09/2023	05/17/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	8	26.66700	Replenished	05/19/2023	1002221549	3133876131
False	9544218		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012712	MR00072992	00	05/30/2023	05/30/2023	06/01/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	84	8	9.52400	Replenished	06/05/2023	1002226246	3135522745
False	8161964		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	10	8.33300	Replenished		1002154521	3117768445
False	8161965		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	10	8.33400	Replenished		1002160851	3118886766
False	8332397		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	10	7.40700	Replenished		1002167937	3121218015
False	8426262		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012540	MR00072992	00	01/27/2023	01/27/2023	01/28/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	84	10	11.90500	Replenished		1002168592	3121399109
False	9558083		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012712	MR00072992	00	05/30/2023	05/30/2023	06/01/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	84	10	11.90500	Replenished	06/05/2023	1002226246	3135522745
False	8682290		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012574	MR00076060	00	02/21/2023	02/21/2023	02/25/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	90	11	12.22200	Replenished		1002182991	3124681386