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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	3041641		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000772971	MR00041417	04	03/04/2021	03/04/2021	03/05/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	30	30	100.00000	Replenished		1001822140	3049139687
False	3041645		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778940	MR00179628	02	03/04/2021	03/04/2021	03/05/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	30	30	100.00000	Replenished		1001822140	3049139687
False	3056748		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776052	MR00189272	02	03/08/2021	03/08/2021	03/09/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001823796	3049396293
False	3059557		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776052	MR00189272	02	03/08/2021	03/08/2021	03/09/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001823796	3049396293
False	3059559		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776052	MR00189272	02	03/08/2021	03/08/2021	03/09/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33400	Replenished		1001823796	3049396293
False	3056710		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778084	MR00279358	00	03/08/2021	03/08/2021	03/09/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001823796	3049396293
False	3059556		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778084	MR00279358	00	03/08/2021	03/08/2021	03/09/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001823796	3049396293
False	3059558		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778084	MR00279358	00	03/08/2021	03/08/2021	03/09/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33400	Replenished		1001823796	3049396293
False	3077426		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776070	MR00255721	02	03/11/2021	03/11/2021	03/12/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001825446	3049810902
False	3079465		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776070	MR00255721	02	03/11/2021	03/11/2021	03/12/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001825446	3049810902