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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	4977675		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	00	11/17/2021	11/17/2021	11/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1001975684	3077386382
False	5210212		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	01	12/17/2021	12/17/2021	12/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1001975684	3077386382
False	5215880		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	01	12/17/2021	12/17/2021	12/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002041590	3090640344
False	5960100		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	00	03/28/2022	03/28/2022	03/29/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1002041590	3090640344
False	6157411		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	01	04/22/2022	04/22/2022	04/23/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002041590	3090640344
False	6161796		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	01	04/22/2022	04/22/2022	04/23/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002062156	3095062963
False	6449128		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	02	06/02/2022	06/02/2022	06/03/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1002062156	3095062963
False	6802210		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	03	07/05/2022	07/05/2022	07/06/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1002087483	3101872453
False	7045016		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	04	08/05/2022	08/05/2022	08/06/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002087483	3101872453
False	7049033		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	04	08/05/2022	08/05/2022	08/06/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002114625	3108158138