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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	7470767		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	06	10/03/2022	10/03/2022	10/04/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002114625	3108158138
False	7474283		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	06	10/03/2022	10/03/2022	10/04/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002129814	3111983748
False	9451167		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	06	05/22/2023	05/22/2023	05/23/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished	06/29/2023	1002238604	3138299994
False	7286277		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	05	09/07/2022	09/07/2022	09/10/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1002114625	3108158138
False	9209533		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	05	04/24/2023	04/24/2023	04/25/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished	05/02/2023	1002210717	3131427601
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
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	8885313		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	04	03/20/2023	03/20/2023	03/21/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002193992	3127402543
False	8890573		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	04	03/20/2023	03/20/2023	03/21/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished	05/02/2023	1002210717	3131427601
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