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Submitting Entity | Member ID | Claim Number | Gender | Year of Birth | Paid Date | Fill Date | Drug Name | Pharmacy Number | Script Number |
73288 | 7171004171117 | 34z143454531 | F | 1945 | 8/3/2018 | 8/2/2018 | HYDROCODONE/ACETAMINOPHEN | 410263 | 306174 |
79413A | 116174145414 | 113573z37733351111Q | M | 1972 | 12/23/2019 | 12/23/2019 | LISINOPRIL TAB 5MG | 418613 | 306174 |
79413A | 784011857 | 1513z5313147307114Q | M | 1936 | 5/16/2015 | 5/16/2015 | HYDROCODONE-ACETAMINOPHEN | 419766 | 306174 |
79413D | EA470177RCOX | 1105443z4571013 | F | 1942 | 2/27/2019 | 2/27/2019 | HYDROCODONE/ACETAMINOPHEN | 419398 | 306174 |
95885 | 810004587177 | 35z434073171 | M | 1983 | 10/10/2015 | 10/9/2015 | OXYCODONE/ACETAMINOPHEN | 414780 | 306174 |
99EBD1 | 11001401 | 14300z540543015 | F | 1983 | 10/27/2014 | 10/27/2014 | AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG | NULL | 306174 |
99EBD1 | 87707101 | 533z0174z4 | M | 1961 | 9/8/2016 | 9/8/2016 | HYDROCODONE/ACETAMINOPHEN | NULL | 306174 |
99MCD1 | 518567101 | 40143310011z3 | F | 1962 | 11/27/2014 | 11/17/2014 | HYDROCODONE-ACETAMINOPHEN 5-32 | 140048407 | 306174 |
99MCD1 | 7174417701 | 40151z703zz43 | M | 2002 | 6/25/2015 | 6/16/2015 | FOCALIN XR 20 MG CAPSULE | 146315407 | 306174 |
99MCD1 | 7671700701 | 4013343037551 | M | 2002 | 12/19/2013 | 12/9/2013 | FOCALIN XR 15 MG CAPSULE | 140029407 | 306174 |
99MCD1 | 7711717701 | 4014047047034 | M | 2013 | 4/3/2014 | 3/28/2014 | AMOX-CLAV 600-42.9 MG/5 ML SUS | 137403407 | 306174 |