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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
2934475
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011235
MR00206514
00
01/29/2021
01/29/2021
01/30/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
20
44.44400
Replenished
1001826768
3050065355
False
2934474
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011235
MR00206514
00
01/29/2021
01/29/2021
01/30/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
25
55.55600
Replenished
1001803996
False
2958383
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011267
MR00283017
00
02/17/2021
02/17/2021
02/18/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
40
40
100.00000
Replenished
1001826768
3050065355
False
3080850
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011323
MR00051318
00
03/12/2021
03/12/2021
03/13/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
20
20
100.00000
Replenished
1001826768
3050065355
False
3110965
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011324
MR00206514
00
03/15/2021
03/15/2021
03/16/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
20
44.44400
Replenished
1001826768
3050065355
False
3116484
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011324
MR00206514
00
03/15/2021
03/15/2021
03/16/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
25
55.55600
Replenished
1001834470
3051403571
False
3136405
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011334
MR00283017
00
03/18/2021
03/18/2021
03/19/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
40
40
100.00000
Replenished
1001834470
3051403571
False
3166420
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011350
MR00051318
00
03/24/2021
03/24/2021
03/25/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001834470
3051403571
False
3197282
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011359
MR00195562
00
03/29/2021
03/29/2021
03/30/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
5
16.66700
Replenished
1001834470
3051403571
False
3203468
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011359
MR00195562
00
03/29/2021
03/29/2021
03/30/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
25
83.33300
Replenished
1001849254
3054056167