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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
2934039
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004010843
MR00085254
01
10/05/2020
10/05/2020
10/05/2020
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
10
33.33300
Replenished
1001744025
False
2934040
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004010843
MR00085254
01
10/05/2020
10/05/2020
10/05/2020
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
20
66.66700
Replenished
1001838628
3052278966
False
2934038
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011051
MR00085254
00
11/10/2020
11/10/2020
11/10/2020
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
30
100.00000
Replenished
1001838628
3052278966
False
3266014
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011051
MR00085254
02
04/06/2021
04/06/2021
04/06/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
10
33.33300
Replenished
1001935866
3069727218
False
3260720
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011051
MR00085254
02
04/06/2021
04/06/2021
04/06/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
20
66.66700
Replenished
1001838628
3052278966
False
2934037
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011051
MR00085254
01
01/22/2021
01/22/2021
01/23/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
30
100.00000
Replenished
1001838628
3052278966
False
3714026
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011514
MR00085254
00
06/07/2021
06/07/2021
06/07/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
30
100.00000
Replenished
1001935866
3069727218
False
4214276
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011655
MR00085254
00
08/06/2021
08/06/2021
08/06/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
30
100.00000
Replenished
1001935866
3069727218
False
4660411
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011780
MR00085254
00
10/04/2021
10/04/2021
10/04/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
30
100.00000
Replenished
1001935866
3069727218
False
4874978
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000004011845
MR00085254
00
11/03/2021
11/03/2021
11/03/2021
00054485925
TRIAZOLAM 0.25 MG TABLET
0.25 MG
TABLET
100
30
30
100.00000
Replenished
1002046742
3092154588