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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	2948701		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779904	MR00155501	00	02/15/2021	02/15/2021	02/16/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001811232	987509358
False	2951907		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779904	MR00155501	00	02/15/2021	02/15/2021	02/16/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001811232	987509358
False	2951908		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779904	MR00155501	00	02/15/2021	02/15/2021	02/16/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33400	Replenished		1001811232	987509358
False	3456015		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774641	MR00079005	03	04/29/2021	04/29/2021	04/30/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001850989	3054468652
False	3462858		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774641	MR00079005	03	04/29/2021	04/29/2021	04/30/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001850989	3054468652
False	3462859		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774641	MR00079005	03	04/29/2021	04/29/2021	04/30/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33400	Replenished		1001850989	3054468652
False	3582767		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782013	MR00155501	00	05/18/2021	05/18/2021	05/19/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001860966	3056169530
False	3589474		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782013	MR00155501	00	05/18/2021	05/18/2021	05/19/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001860966	3056169530
False	3589475		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782013	MR00155501	00	05/18/2021	05/18/2021	05/19/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33400	Replenished		1001860966	3056169530
False	4147180		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783622	MR00079005	00	07/28/2021	07/28/2021	07/29/2021	43598050530	RALOXIFENE HCL 60 MG TABLET	60 MG	TABLET	30	90	30	33.33300	Replenished		1001897770	3062993331