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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	8765203		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796512	MR00395196	00	03/06/2023	03/06/2023	03/07/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	60	100.00000	Replenished		1002198481	3129060211
False	9025102		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796820	MR00395196	00	03/31/2023	03/31/2023	04/01/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	20	33.33300	Replenished	08/22/2023	1002249419	3140846557
False	9004073		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796820	MR00395196	00	03/31/2023	03/31/2023	04/01/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	40	66.66700	Replenished		1002198481	3129060211
False	9209518		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796820	MR00395196	01	04/24/2023	04/24/2023	04/25/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	60	100.00000	Replenished	08/22/2023	1002249419	3140846557
False	9988314		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797868	MR00395196	02	07/20/2023	07/20/2023	07/21/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	20	33.33300	Replenished	08/22/2023	1002249419	3140846557
False	9993514		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797868	MR00395196	02	07/20/2023	07/20/2023	07/21/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	40	66.66700	Replenished	08/23/2023	1002261840	3144399971
False	10206035		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797868	MR00395196	03	08/21/2023	08/21/2023	08/22/2023	68001023800	CLONIDINE HCL 0.2 MG TABLET	0.2 MG	TABLET	100	60	60	100.00000	Replenished	08/23/2023	1002261840	3144399971