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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	2976598		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774987	MR00210929	01	02/22/2021	02/22/2021	02/23/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	90	30	33.33300	Replenished		1001816056	987916714
False	2978590		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774987	MR00210929	01	02/22/2021	02/22/2021	02/23/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	90	30	33.33300	Replenished		1001816056	987916714
False	2978591		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774987	MR00210929	01	02/22/2021	02/22/2021	02/23/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	90	30	33.33400	Replenished		1001816056	987916714
False	3622365		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774987	MR00210929	02	05/24/2021	05/24/2021	05/25/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	90	30	33.33300	Replenished		1001863873	3056827847
False	3625923		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774987	MR00210929	02	05/24/2021	05/24/2021	05/25/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	90	30	33.33300	Replenished		1001863873	3056827847
False	3625924		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774987	MR00210929	02	05/24/2021	05/24/2021	05/25/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	90	30	33.33400	Replenished		1001863873	3056827847
False	3166406		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777580	MR00145513	02	03/24/2021	03/24/2021	03/25/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	30	30	100.00000	Replenished		1001831820	3050993427
False	3414282		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777580	MR00145513	03	04/23/2021	04/23/2021	04/24/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	30	30	100.00000	Replenished		1001848263	3053810034
False	2988209		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780136	MR00388862	00	02/24/2021	02/24/2021	02/25/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	30	30	100.00000	Replenished		1001816771	988000091
False	3173273		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780136	MR00388862	01	03/25/2021	03/25/2021	03/26/2021	68382000106	PAROXETINE HCL 40 MG TABLET	40 MG	TABLET	30	30	30	100.00000	Replenished		1001832780	3051158401