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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	9004022		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790673	MR00234113	03	04/01/2023	04/01/2023	04/02/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished		1002198481	3129060211
False	8637265		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796173	MR00182714	00	02/17/2023	02/20/2023	02/21/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished		1002180956	3124348932
False	8637256		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796188	MR00389245	00	02/20/2023	02/20/2023	02/21/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished		1002180956	3124348932
False	9397915		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795883	MR00230427	01	05/08/2023	05/08/2023	05/17/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9397857		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797864	MR00182714	00	05/10/2023	05/10/2023	05/17/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9470436		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798111	MR00389245	00	05/23/2023	05/23/2023	05/24/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished	05/26/2023	1002223394	3134652724
False	9825575		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798903	MR00234113	00	06/30/2023	06/30/2023	07/01/2023	59651005290	EZETIMIBE 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished	07/03/2023	1002239529	3138618794