TW 1

I.
Lampiran III JML OBAT KELUAR TRI I
NAMA OBAT JLH DISTR HARGA

NO KODE OBAT SATUAN NO BATCH EXPIRED Jumlah Ket
( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
1 Albendazol 400 mg Tablet 85606001 - Okt-20 Rp 690 Rp -
2 Alopurinol 100 mg Tablet 18F129 - Jun-19 Rp 88 Rp -
3 Ambroxol sirup 15 mg/ml Botol 1603026 2,450 Mar-19 Rp 4,520 Rp 11,074,000
4 Ambroxol tablet 30 mg Tablet 95483007 - Apr-18 Rp 260 Rp -
5 Aminopilin 200 mg Tablet T. 2550021 11,700 Jul-19 Rp 162 Rp 1,895,400
6 GKL8713603943Aminopilin Injeksi 24 mg /ml-10ml Ampul 1411015 60 Sep-18 Rp 4,013 Rp 240,780
7 GKL8920905817Amitriptilin 25 mg Tablet 1503002 100 Mar-19 Rp 117 Rp 11,700
8 Amlodipin tablet 5 mg Tablet 18H024 - Aug -17 Rp 192 Rp -
9 Amoksisilin Dry Syrup 125mg/5ml Botol 1509-16-96 1,740 Sep-18 Rp 2,500 Rp 4,350,000
10 Amoksisilin sirup kering forte 250 mg/5 ml Botol 620 Rp 4,212 Rp 2,611,440
11 Amoksisilin 250 mg Kapsul 1605/02-051 52,500 5/31/2020 Rp 201 Rp 10,552,500
PJ018236,PJ0
12 Amoksisilin 500 mg Kaplet 155,000 Jul-19 Rp 233 Rp 36,115,000
18237
13 Ampisilina Dry Syrup 125mg/5ml Botol - Rp -
14 Ampisilina inj 1000 mg/ml Vial - Rp -
15 Antalgin 500 mg Tablet 85314001zn - Feb-17 Rp 76 Rp -
16 Antalgin injeksi 250mg/ml-2ml Ampul - Rp -
17 Antasida DOEN Tablet 5549533 104,100 Nov-17 Rp 63 Rp 6,558,300
18 Antasida Doen Suspensi Botol 155H026 1,200 Nov-18 Rp 2,065 Rp 2,478,000
19 Anti Bakteri DOEN salap Tube 1507007 952 Jul-19 Rp 2,641 Rp 2,514,232
20 Anti Haemoroid suppos Suppos A5013 862 Jan-19 Rp 3,197 Rp 2,755,814
21 Anti Fungi DOEN salap Pot 15A02 780 Feb-20 Rp 1,982 Rp 1,545,960
Anti Malaria DOEN Kombinasi : Pirimetamin 25
22 mg + Sulfadoksin 500 mg Tablet H1211738 - Aug -17 Rp 597 Rp -
23 Anti Migrain Tablet 050016 - Mei -18 Rp 6,748 Rp -
24 Aqua Pro Injeksi steril Ampul P1J43642 - Aug -17 Rp 2,105 Rp -
25 GBL9514103110Asam Folat tab 1 mg Tablet 681603153 3,900 Mar-18 Rp 50 Rp 195,000
26 Afolat-Asam Folat Tab 0,4 mg Tablet T03098AF - Aug-21 Rp 66 Rp -
27 Asam Mefenamat 500 mg Tablet - Rp 116 Rp -
28 Asam Traneksamat 500mg Tablet TSE63644 - Jun-18 Rp 1,915 Rp -
29 Vitamin C 50 mg Tablet F151006B 83,800 Jun-18 Rp 109 Rp 9,134,200
30 Asam Klorida 0,1 N Botol - Rp -
31 Asam Sulfosalisilat Botol - Rp -
32 Acetosal 100 mg Tablet - Rp 134 Rp -
33 Acetosal 500 mg Tablet - Rp -
34 Acyclovir krim tube 5 g Tube 55305001BA - Dec-16 Rp 3,148 Rp -
35 Acyclovir tab 200 mg Tablet 1605009 8,600 6/1/2021 Rp 261 Rp 2,244,600
36 Acyclovir tab 400 mg Tablet dg0800j 8,800 Apr-21 Rp 360 Rp 3,168,000
37 GKL9520906143Atropin Sulfat Injeksi 0,25 mg/ml-1ml Ampul 1304005 - Apr-18 Rp 1,291 Rp -
38 Atropin Sulfat 0,5 mg Tablet - Rp 77 Rp -
39 Atapulgit tab 600 mg(Pularex) Tablet 12207516 - Jul-17 Rp 210 Rp -
40 Benzatin penisillin 1,2 UI/ml vial 9532000 - Okt-20 Rp 11,235 Rp -
41 GKL9912700129Betametason Cream Tube 650770T 1,752 Jun-18 Rp 1,407 Rp 2,465,064
42 Bisacodil 10 mg Suppos PL9911 144 Jul-17 Rp 6,045 Rp 870,480
43 Cefixime kapsul 100 mg Kapsul PG048037 5,200 Jul-19 Rp 626 Rp 3,255,200
44 Cefixime sirup kering 100 mg/5 ml Botol PH358041 508 Aug-18 Rp 7,490 Rp 3,804,920
45 Cetirizine 10 mg tablet Tablet 603083 13,300 Mar-19 Rp 145 Rp 1,928,500
46 Cetirizine 5 mg/5 ml sirup Botol 1601039 - Jan-18 Rp 7,082 Rp -
47 Depakene-Valproat sirup 250mg/5 ml Botol - Rp 41,800 Rp -
48 Deksametason Injeksi 5 mg / ml-1ml Ampul 95337020-1 1,700 Jul-19 Rp 1,580 Rp 2,686,000
49 GKL0133202910Deksametason 0,5 mg Tablet 00714L0040 20,900 Dec-17 Rp 64 Rp 1,337,600
50 Dextromethorphan HBr Syrup Botol - Rp 1,423 Rp -
51 Dextromethorphan HBr 15 mg Tablet B120182B - Feb-17 Rp 97 Rp -
52 Diazepam injeksi 5 mg/ml-2ml Ampul 1503007 - Apr-20 Rp 5,788 Rp -
53 Diazepam 5 mg Tablet 7,600 Rp 122 Rp 927,200
54 Diazepam 2 mg Tablet 8534002 - Des-20 Rp 148 Rp -
55 Diphenhidramin Injeksi 10 mg/ml-1ml Ampul 121D005 - Apr-17 Rp 1,107 Rp -
56 Digoksin 0,25 mg Tablet - Rp 150 Rp -
57 GKL1234010410Domperidon tablet 10 mg Tablet 140807149 6,800 Aug-18 Rp 118 Rp 802,400
58 Domperidon Suspensi 5 mg/5 ml btl 60 ml 150709149 271 Jul-19 Rp 3,410 Rp 924,110
59 Efedrin HCl 25 mg Tablet - Rp 54 Rp -
60 Efinefrin Injeksi Ampul 653440092 - Jul-16 Rp 8,505 Rp -
61 Ekstrak Beladona Tablet - Rp -
62 Eritromosin kaplet 500 mg Kaplet t2214af 5,000 Dec-19 Rp 751 Rp 3,755,000
63 Eritromosin kaplet 250 mg Kaplet 16cf008 - Jun-19 Rp 594 Rp -
64 Eritromosin sirup 200 mg/ml botol 84 Rp 7,893 Rp 663,012
65 Etakridina Laktat Lar. (Rivanol) Botol - Rp 3,650 Rp -
66 Etanol 70 % 1000 ml Botol - Rp 20,562 Rp -
67 Etanol 70 % cairan 100 ml Botol 15770203 - Mar-19 Rp 4,690 Rp -
68 Eter Anestikus Botol - Rp -
69 Fenitoin Natrium 30 mg Kapsul - Rp -
70 Fenobarbital Injeksi 50 mg/ml-2ml Ampul 75803001 - Rp 2,068 Rp -
71 Fenobarbital 100 mg Tablet - Rp -
72 Fenobarbital 30 mg Tablet 1502005 2,400 Apr-20 Rp 260 Rp 624,000
PKM SEMERAP 2016 1

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
73 Fenoksi Metil Fenicilin 500 mg Tablet - Rp -
74 Fenol Gliserol Tetes Telinga 10 % Botol - Rp 1,058 Rp -
75 Fitomenadion Injeksi 10 mg/ml-1ml Ampul - Rp 1,644 Rp -
76 Fitomenadion 10 mg Tablet 95381002 14,500 Apr-19 Rp 730 Rp 10,585,000
77 Furosemida 40 mg Tablet EF0401 - Jun-20 Rp 1,375 Rp -
78 Garam Oralit Kombinasi Sachet - Rp 269 Rp -
79 Gameksan Emulsi Botol -
80 Gentamisin inj 80 mg/ml Ampul - Rp -
81 Gentian Violet 1 % Botol 002083 - Agust-20 Rp 3,487 Rp -
82 Glibenklamid 5 mg Tablet - Rp 89 Rp -
83 GBL1025803510Gliseril Guayakolat 100 mg Tablet 1502150 - Feb-18 Rp 125 Rp -
84 Gliserin Botol - Rp 3,650 Rp -
85 Glukosa Lar. 10 % Infus Botol 230916 100 Agt-18 Rp 7,500 Rp 750,000
86 Glukosa Lar. 5 % Infus Botol 220724 180 Jul-17 Rp 6,900 Rp 1,242,000
87 Griseofulfin 125 mg Tablet - Sep-19 Rp 313 Rp -
88 Haloperidol 0,5 mg Tablet 1606121 11,200 6/1/2019 Rp 62 Rp 694,400
89 Haloperidol 1,5 mg Tablet - Rp 72 Rp -
90 Haloperidol 5 mg Tablet - Rp 91 Rp -
91 Hidroklorotiazid ( HCT ) Tablet - Rp -
92 Hidrogen Peroksida 3 % Botol - Des-18 Rp 299,613 Rp -
93 Hidrokortison Cream Tube 660772T 1,370 Feb-20 Rp 2,650 Rp 3,630,500
94 Hyocine-N-Butilbromide tablet 10 mg tablet - Rp 2,048 Rp -
95 Hyocine-N-Butilbromide inj 20 mg/ml Ampul 5G0328 100 Jul-18 Rp 4,725 Rp 472,500
96 Ibuprofen 200 mg Tablet 160501177 25,400 5/31/2020 Rp 108 Rp 2,743,200
97 Ibuprofen 400 mg Tablet AF911921 33,100 Jun-20 Rp 130 Rp 4,303,000
98 Isoniazide 300 mg Tablet - Rp -
99 GKL8920920908Isosorbit Dinitrat Tablet 1605016 - Jun-20 Rp 146 Rp -
100 Kalsium Laktat Tablet - Rp 49 Rp -
101 Kaptopril tablet 12.5 mg Tablet 1504028 - Jul-19 Rp 63 Rp -
102 Kaptopril tablet 25 mg Tablet - Rp 71 Rp -
103 Ketokenazol 200 mg Tablet 2761256 - Jun-19 Rp 629 Rp -
104 Klindamisin kapsul 300 mg kapsul - Rp 553 Rp -
105 Kloramfenikol 250 mg Kapsul - Rp 213 Rp -
106 Kloramfenikol salep Mata 1% Botol 036007 336 Mar-19 Rp 1,800 Rp 604,800
Kloramfenikol tetes Mata 3% Botol - Jan-18 Rp 8,753 Rp -
107 Kloramfenikol Tetes Telinga 3 % Botol 651043 - Jan-18 Rp 6,720 Rp -
108 Kloramfenikol suspensi 125 mg/5 ml botol 495 Rp 3,978 Rp 1,969,110
109 D2020708 Klorfeniramin Maleat ( CTM ) Tablet 1606/01152 269,100 Jan-20 Rp 43 Rp 11,571,300
110 Klorokuin 250 mg Botol - Rp -
111 Klorfromazin HCl 100 mg Tablet - Rp 140 Rp -
112 Klorfromazin HCl 25 mg Tablet 65328006 10,400 Sep-16 Rp 155 Rp 1,612,000
113 Klorpropamid 100 mg Tablet - Rp -
114 Kodein HCl 10 mg Tablet - Rp 575 Rp -
115 Kotrimoksazol 120 mg (Pediatrik) Tablet - Rp -
116 Kotrimoksazol 960 mg Tablet - Rp 154 Rp -
117 Kotrimoksazol Suspensi Botol 2808023 977 Agt-16 Rp 2,183 Rp 2,132,791
118 Laktulosa Sirup 3,335 g/5ml Botol 270100214 - Mei-18 Rp 14,500 Rp -
119 Lansoprazol kapsul 30 mg kapsul - Rp 473 Rp -
120 Larutan Benedict Botol - Rp 166,600 Rp -
121 Larutan Eosin 2 % Botol 1 Rp 139,145 Rp 139,145
122 Larutan Etanol Botol - Rp -
123 Larutan Giemsa Stain Botol - Rp 322,400 Rp -
124 Larutan HCl 0,1 % Botol 100 ml - Rp 21,774 Rp -
125 Larutan HCl 0,1 % Botol 50 ml 5 Rp 9,313 Rp 46,565
126 Larutan Karbol Fuksin Botol - Rp 380,100 Rp -
127 Larutan Kinyon Botol - Rp -
128 Larutan Metilen Biru Botol - Rp 72,100 Rp -
129 Larutan Turk Botol - Rp 106,800 Rp -
130 Lidokain Komp. Injeksi Ampul 95362034-2 3,000 May-20 Rp 870 Rp 2,610,000
131 Lisol Botol 8 Rp 164,488 Rp 1,315,904
132 Loperamide 2 mg Tablet 50506 13,800 Jul-18 Rp 87 Rp 1,200,600
133 Magnesium sulfat injeksi 20% 5-25 ml Ampul - Rp 3,200 Rp -
134 Magnesium sulfat injeksi 40 % Ampul - Rp 3,650 Rp -
135 Mebendazol 100 mg Tablet - Rp -
136 Metanol Botol - Rp 23,938 Rp -
137 Metformin 500 mg tablet Tablet - Rp 115 Rp -
138 Metil Ergometrin 0,125 mg Tablet 18G250 5,800 Sep-19 Rp 3,115 Rp 18,067,000
139 Metil Ergometrin Injeksi Ampul - Rp 1,565 Rp -
140 Metilprednisolon 4 mg tablet YY002 20,300 5/30/2019 Rp 202 Rp 4,100,600
141 Metoklopramid 5 mg tablet - Rp 108 Rp -
142 Metoklopramid 10 mg tablet WE079A 13,500 May-21 Rp 95 Rp 1,282,500
143 Metoklopramid inj 5 mg/ml Ampul - Rp 10,247 Rp -
144 Metronidazol 500 mg Tablet T1751068 18,800 Jul-18 Rp 133 Rp 2,500,400
145 Metronidazol sirup 125 mg/5 ml Botol - Rp 3,800 Rp -
146 Mikonazol krim/salep 2% (Nitrat) tube 046057W 528 Apr-20 Rp 3,410 Rp 1,800,480
147 Minyak Emersi Botol 281115 - Jan-18 Rp 1,703,740 Rp -
PKM SEMERAP 2016 2

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
148 N-asetilsistein 200 mg kapsul 1605043 600 01/06/18 Rp 447 Rp 268,200
149 Natrium Trioksin 100 mcg Tablet - Rp -
150 Natrium Bikarbonat Tablet - Rp 39 Rp -
151 Natrium Diklofenak tablet 50 mg Tablet 95365009R 38,000 3/30/2019 Rp 160 Rp 6,080,000
152 Natrium Klorida 0,9% Infus Botol 260408 610 Mar-21 Rp 6,410 Rp 3,910,100
153 Nifedipin tab 10 mg Tablet - Rp 100 Rp -
154 Nifedipin tab 20 mg,slow release;oros Blister - Rp 2,999 Rp -
155 Nystatin Tablet Vagina Tablet 95372003 2,400 Rp 160 Rp 384,000
156 OAT Kategori Anak Paket 2 Rp 225,739 Rp 451,478
157 Obat TB FDC kategori I dewasa Paket 25 Rp 377,985 Rp 9,449,625
158 Obat TB kategori II Paket - Rp 1,259,989 Rp -
159 Obat Batuk Hitam ( OBH ) Botol 1510012 2,520 Oct-19 Rp 12,590 Rp 31,726,800
160 Oksitetrasiklin injeksi 50 mg/ml-10ml Vial - Rp -
161 Oksitetrasiklin Salap kulit 3 % Tube - Rp -
162 Oksitetrasiklin Salap Mata 1 % Tube 5-51006 14 Oct-20 Rp 20,170 Rp 282,380
163 Oksitosin Injeksi Ampul - Rp 1,820 Rp -
164 Omeprazol kapsul 20 mg Kapsul HG1835 4,440 Feb-20 Rp 164 Rp 728,160
165 Prokain Penicillin inj Vial - Rp -
166 Parasetamol Syrup Botol J19401 5,376 Oct-17 Rp 1,119 Rp 6,015,744
167 Parasetamol 500 mg Tablet 00814L0070 230,000 Dec-19 Rp 84 Rp 19,320,000
168 Parasetamol 100 mg Tablet - Rp -
169 Parasetamol drops 100 mg/ml Botol 1604017 - 01/04/18 Rp 5,460 Rp -
170 GNL7212416643Pethidin HCl Injeksi 50 mg/ml-2ml Ampul ID 1596J - Agt-19 Rp 15,225 Rp -
171 Pirantel 500 mg Tablet - Mei-20 Rp 13,385 Rp -
172 Piridoksin ( Vit. B 6 ) Tablet - Rp 124 Rp -
173 Piroksikam 20 mg Tablet 160359 - Rp 156 Rp -
174 Prednison Tablet 160481 - Apr-19 Rp 94 Rp -
175 Primakuin Tablet - Rp -
176 Propil thio urasil ( PTU ) Tablet 1506010 11,500 Mei-21 Rp 433 Rp 4,979,500
177 Propanolol 10 mg Tablet 18,000 Rp 66 Rp 1,188,000
178 Propranolol 40 mg Tablet 47H0643 - Jul-21 Rp 160 Rp -
179 Ranitidin 10 mg Tablet 4GE4123 140,100 Aug-17 Rp 115 Rp 16,111,500
180 Ranitidin injeksi 25 mg/5 ml ampul - Rp 1,157 Rp -
181 Reagen Zihl Nielsen Paket 2250916 - Sep-19 Rp 3,761,865 Rp -
182 Reserpin 0,25 mg Tablet - Rp - Rp -
183 Ringer Laktat lar. infus Botol 330905 - Aug-18 Rp 5,460 Rp -
184 Salap 2-4 kombinasi Pot - Rp 1,700 Rp -
185 Salbutamol tab 4 mg Tablet E150761B 11,400 May-20 Rp 83 Rp 946,200
186 Salisil bedak Kotak 114237 320 Nov-17 Rp 1,046 Rp 334,720
187 Sefotaksim injeksi 1 gram vial 170 Rp 5,925 Rp 1,007,250
188 Serum Anti Bisa ular Polivalen 5 ml Vial 47004716 - Jun-18 Rp 702,640 Rp -
189 Serum Anti Tetanus 1.500 UI Ampul 4200416 - Feb-18 Rp 311,365 Rp -
190 Serum Anti Tetanus 20.000 UI Vial - Rp -
191 Sianokabalamin Injeksi 500 Mcg/ml Ampul 1310018 - Oct-18 Rp 1,132 Rp -
192 Simvastatin 5 mg tablet - Rp -
193 Siprofloksasin 500 mg Tablet 60641108 60,200 6/1/2020 Rp 289 Rp 17,397,800
194 Spironolakton tablet 100 mg Tablet 500 Rp 878 Rp 439,000
195 Stesolid-Diazepam larutan rektal 5 mg/2.5 ml Tube - Rp 12,155 Rp -
196 Stesolid-Diazepam larutan rektal 10 mg/2.5 ml Tube R23691715 530 Sep-17 Rp 17,600 Rp 9,328,000
197 Sulfadimidin Tablet - Rp -
198 Tablet Tambah Darah tablet - Feb-19 Rp 1,380 Rp -
199 Taburia Sachet - Rp 6,300 Rp -
200 Tetrasiklin HCl 250 mg Kapsul - Rp -
201 Tetrasiklin HCl 500 mg Kapsul - Rp 377 Rp -
202 Tetrakain Tetes Mata 0,5 % Botol - Rp -
203 Thiamin HCl 50 mg ( Vit. B 1 ) Tablet 71,000 Rp 89 Rp 6,319,000
204 Thiamin HCl injeksi 100mg /ml-1ml Ampul - Rp 700 Rp -
205 Triheksifenidil 2 mg Tablet - Rp 40 Rp -
206 Vaksin Rabies Vero Vial - Rp 218,122 Rp -
207 Vit. A 100.000 IU Kapsul - Rp 298 Rp -
208 Vit. A 200.000 IU Kapsul 075085w - Jul-18 Rp 482 Rp -
209 GBL1312702210Vitamin B komplex Tablet K40644T 129,800 Sep-17 Rp 121 Rp 15,705,800
210 Yodium Povidon 10 % - 30 ml Botol F18502 - Jul-18 Rp 2,250 Rp -
211 Yodium Povidon 10 % - 60 ml Botol 30 Rp 6,550 Rp 196,500
212 Yodium Povidon 10 % - 300 ml Botol K18507 45 Nop-18 Rp 39,470 Rp 1,776,150
213 Zinc tablet 20 mg Tablet 1507093 8,200 Agust-18 Rp 540 Rp 4,428,000
214 Zinc drop 10 mg/ml Botol - Rp 12,840 Rp -
215 Zinc sir 20 mg/5ml Botol 60 ml 277 Rp 7,770 Rp 2,152,290
216 Zinc sir 10 mg/5ml Botol 100 ml - Rp 15,732 Rp -
OBAT GIGI
1 Air Raksa Dental Use Botol - Rp 203,996 Rp -
2 Devitalisasi pasta (non Arsen) btl 1881605 - Apr-19 Rp 704,990 Rp -
3 Etil klorida Semprot Tabung 2 Rp 168,012 Rp 336,024
4 Eugenol Cairan Botol 8 Rp 19,005 Rp 152,040
5 Glas Ionomer Cement Set - Rp -
PKM SEMERAP 2016 3

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
6 Kalsium Hidroksida Pasta kotak - Rp 329,995 Rp -
7 Klorfenol kamfer Menthol ( CHKM ) botol 246/16 - Apr-19 Rp 187,990 Rp -
8 Mummifying Pasta Botol - Rp 561,900 Rp -
9 Semen seng fosfat Cairan Dan Serbuk Set - Rp 256,600 Rp -
10 Silver Amalgam serbuk Botol - Rp 723,800 Rp -
Temporary Stopping Fletcher (Fletcher) serbuk
11 dan cairan Botol - Rp 63,100 Rp -
PERBEKALAN KESEHATAN
1 Alat Suntik Sekali Pakai 1 ml Set 810 700 Agust-19 Rp 762 Rp 533,400
2 Alat Suntik Sekali Pakai 3 ml Set 1503201 - Apr-20 Rp 802 Rp -
3 Alat suntik sekali pakai 5 ml Set - Mei-21 Rp 903 Rp -
4 Alat suntik sekali pakai 10 ml Set - Agust-19 Rp 1,103 Rp -
5 Catgut No. 2/0 dengan jarum bedah pcs 150901 - Sep-18 Rp 32,800 Rp -
7 Ecolab aquagel sterile jelly 82 gr Tube 3246LE1 - May-18 Rp 42,588 Rp -
8 Foley Catheter 14 fr pcs 21H15 - Feb-20 Rp 18,450 Rp -
10 Foley Catheter 18 fr pcs 21H15 - Jun-20 Rp 18,450 Rp -
11 Handscoon S pcs 1603033 - May-21 Rp 46,200 Rp -
12 Handscoon M pcs 1603023 - May-21 Rp 46,200 Rp -
13 Handscoon L pcs 1603013 - May-21 Rp 46,200 Rp -
14 Infusion Set Anak pcs 395 Rp 4,837 Rp 1,910,615
15 Iodium test Botol - Rp 293,738 Rp -
16 Infusion Set Dewasa pcs 1,020 Mar-19 Rp 4,232 Rp 4,316,640
17 IV Catheter No.18 G pcs 180 Jun-16 Rp 8,700 Rp 1,566,000
18 IV Catheter No.20 G pcs - Jul-20 Rp 8,700 Rp -
19 IV Catheter No.22 G pcs - Nov-20 Rp 8,700 Rp -
20 IV Catheter No.24 G pcs - Sep-20 Rp 8,700 Rp -
21 Kapas Pembalut / Absorben 250 gram Rol - Rp 13,100 Rp -
22 Kassa Hidropil steril uk. 16x16 (isi 16 lembar ) kotak - Rp 7,900 Rp -
23 Kassa Pembalut Hidropil 40 y x 80 cm Rol - Rp 607 Rp -
24 Kassa Pembalut Hidropil 4 x 10 cm Rol
25 Kassa Pembalut Hidropil 4 x5cm Rol
26 Kassa Pembalut Hidropil 10x4,55 cm Rol - Rp 43,987 Rp -
27 Kassa Pembalut Hidropil 15x4,55 cm Rol 10 Rp 43,987 Rp 439,870
28 Masker pcs 8,250 Oct-20 Rp 647 Rp 5,337,750
29 Policlean Handrub Botol - May-19 Rp 74,494 Rp -
30 Plester 5 yard x 2 inch Rol 174 Nov-19 Rp 17,685 Rp 3,077,190
31 Pot Sputum pot - Rp 7,040 Rp -
32 Silk dengan jarum bedah 2/0 HR pcs - Jul-20 Rp 20,300 Rp -
34 Urine Bag pcs - Rp 4,000 Rp -
JUMLAH (dalam rupiah) Rp 375,457,933
Sungai Penuh,01 Maret 2017
Mengetahui
Kepala Gudang Farmasi
Dinas Kesehatan Kab. Kerinci
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 4

HARGA BARU KLUAR JML JML BARU
690 0 0 0
93 0 0 0
4520 2450 11074000 11074000
260 0 0 0
162 11700 1895400 1895400
4013 60 240780 240780
117 100 11700 11700
192 0 0 0
2500 1740 4350000 4350000
4212 620 2611440 2611440
201 52500 10552500 10552500
233 155000 36115000 36115000
0 0 0
0 0 0
0 0 0
0 0 0
63 104100 6558300 6558300
2065 1200 2478000 2478000
2641 952 2514232 2514232
3197 862 2755814 2755814
1982 780 1545960 1545960
597 0 0 0
6748 0 0 0
2105 0 0 0
50 3900 195000 195000
66 0 0 0
116 0 0 0
1915 0 0 0
109 83800 9134200 9134200
0 0 0
0 0 0
134 0 0 0
0 0 0
3148 0 0 0
261 8600 2244600 2244600
360 8800 3168000 3168000
1291 0 0 0
77 0 0 0
0 0 0
11235 0 0 0
1407 1752 2465064 2465064
6045 144 870480 870480
626 5200 3255200 3255200
7490 508 3804920 3804920
145 13300 1928500 1928500
7082 0 0 0
41800 0 0 0
1580 1700 2686000 2686000
64 20900 1337600 1337600
0 0 0
0 0 0
5788 0 0 0
122 7600 927200 927200
148 0 0 0
1236 0 0 0
0 0 0
118 6800 802400 802400
3410 271 924110 924110
54 0 0 0
8505 0 0 0
0 0 0
751 5000 3755000 3755000
594 0 0 0
7893 84 663012 663012
3650 0 0 0
20562 0 0 0
4690 0 0 0
0 0 0
0 0 0
2068 0 0 0
0 0 0
260 2400 624000 624000
PKM SEMERAP 2016 5

0 0 0
1058 0 0 0
1644 0 0 0
730 14500 10585000 10585000
1375 0 0 0
269 0 0 0
0 0 0
0 0 0
3487 0 0 0
89 0 0 0
125 0 0 0
3650 0 0 0
7500 100 750000 750000
6900 180 1242000 1242000
313 0 0 0
62 11200 694400 694400
71 0 0 0
91 0 0 0
0 0 0
299613 0 0 0
2650 1370 3630500 3630500
2048 0 0 0
4725 100 472500 472500
108 25400 2743200 2743200
130 33100 4303000 4303000
0 0 0
146 0 0 0
49 0 0 0
63 0 0 0
71 0 0 0
629 0 0 0
553 0 0 0
213 0 0 0
1800 336 604800 604800
8753 0 0 0
6720 0 0 0
3978 495 1969110 1969110
43 269100 11571300 11571300
0 0 0
140 0 0 0
155 10400 1612000 1612000
0 0 0
575 0 0 0
0 0 0
154 0 0 0
2183 977 2132791 2132791
14500 0 0 0
473 0 0 0
166600 0 0 0
139145 1 139145 139145
0 0 0
322400 0 0 0
21774 0 0 0
9313 5 46565 46565
380100 0 0 0
0 0 0
72100 0 0 0
106800 0 0 0
870 3000 2610000 2610000
164488 8 1315904 1315904
87 13800 1200600 1200600
3200 0 0 0
3650 0 0 0
0 0 0
23938 0 0 0
115 0 0 0
3115 5800 18067000 18067000
1565 0 0 0
202 20300 4100600 4100600
108 0 0 0
95 13500 1282500 1282500
10247 0 0 0
133 18800 2500400 2500400
3800 0 0 0
3410 528 1800480 1800480
1703740 0 0 0
PKM SEMERAP 2016 6

447 600 268200 268200
0 0 0
39 0 0 0
160 38000 6080000 6080000
6410 610 3910100 3910100
100 0 0 0
2999 0 0 0
160 2400 384000 384000
225739 2 451478 451478
377985 25 9449625 9449625
1259989 0 0 0
12590 2520 31726800 31726800
0 0 0
0 0 0
20170 14 282380 282380
1820 0 0 0
164 4440 728160 728160
0 0 0
1119 5376 6015744 6015744
84 230000 19320000 19320000
0 0 0
5460 0 0 0
15225 0 0 0
13385 0 0 0
124 0 0 0
156 0 0 0
94 0 0 0
0 0 0
433 11500 4979500 4979500
66 18000 1188000 1188000
160 0 0 0
115 140100 16111500 16111500
1157 0 0 0
3761865 0 0 0
0 0 0
5460 0 0 0
1700 0 0 0
83 11400 946200 946200
1046 320 334720 334720
5925 170 1007250 1007250
702640 0 0 0
311365 0 0 0
0 0 0
1132 0 0 0
0 0 0
289 60200 17397800 17397800
878 500 439000 439000
12155 0 0 0
17600 530 9328000 9328000
0 0 0
1380 0 0 0
6300 0 0 0
0 0 0
377 0 0 0
0 0 0
89 71000 6319000 6319000
700 0 0 0
40 0 0 0
165307 0 0 0
298 0 0 0
482 0 0 0
121 129800 15705800 15705800
2250 0 0 0
6550 30 196500 196500
39470 45 1776150 1776150
540 8200 4428000 4428000
12840 0 0 0
7770 277 2152290 2152290
15732 0 0 0
0 0
0 0
203996 0 0 0
704990 0 0 0
168012 2 336024 336024
19005 8 152040 152040
0 0 0
PKM SEMERAP 2016 7

329995 0 0 0
187990 0 0 0
561900 0 0 0
256600 0 0 0
723800 0 0 0
63100 0 0 0
0 0
0 0
762 700 533400 533400
802 0 0 0
903 0 0 0
1103 0 0 0
32800 0 0 0
32800 0 0 0
42588 0 0 0
18450 0 0 0
18450 0 0 0
18450 0 0 0
46200 0 0 0
46200 0 0 0
46200 0 0 0
4837 395 1910615 1910615
293738 0 0 0
4232 1020 4316640 4316640
8700 180 1566000 1566000
8700 0 0 0
8700 0 0 0
8700 0 0 0
13100 0 0 0
7900 0 0 0
607 0 0 0
0 0 0
0 0 0
43987 0 0 0
43987 10 439870 439870
647 8250 5337750 5337750
74494 0 0 0
17685 174 3077190 3077190
7040 0 0 0
20300 0 0 0
19700 0 0 0
4000 0 0 0
375457933 375457933 0KE
PKM SEMERAP 2016 8

I. Lampiran III PUSKESMAS BUKIT KERMAN

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
3 Ambroxol sirup 15 mg/ml Botol 1603026 50 Mar-19 Rp 4,520 Rp 226,000
5 Aminopilin 200 mg Tablet T. 2550021 - Jul-19 Rp 162 Rp -
6 GKL8713603943Aminopilin Injeksi 24 mg /ml-10ml Ampul 1411015 - Sep-18 Rp 4,013 Rp -
7 GKL8920905817Amitriptilin 25 mg Tablet 1503002 - Mar-19 Rp 117 Rp -
9 Amoksisilin Dry Syrup 125mg/5ml Botol 1509-16-96 - Sep-18 Rp 2,500 Rp -
10 Amoksisilin sirup kering forte 250 mg/5 ml Botol - Rp 4,212 Rp -
11 Amoksisilin 250 mg Kapsul 1605/02-051 - 5/31/2020 Rp 201 Rp -
PJ018236,PJ0
18237
17 Antasida DOEN Tablet 5549533 - Nov-17 Rp 63 Rp -
18 Antasida Doen Suspensi Botol 155H026 - Nov-18 Rp 2,065 Rp -
19 Anti Bakteri DOEN salap Tube 1507007 - Jul-19 Rp 2,641 Rp -
20 Anti Haemoroid suppos Suppos A5013 40 Jan-19 Rp 3,197 Rp 127,880
21 Anti Fungi DOEN salap Pot 15A02 48 Feb-20 Rp 1,982 Rp 95,136
24 Aqua Pro Injeksi steril Ampul 260546 - Mei-21 Rp 2,105 Rp -
25 GBL9514103110Asam Folat tab 1 mg Tablet 681603153 - Mar-18 Rp 50 Rp -
29 Vitamin C 50 mg Tablet F151006B 2,000 Jun-18 Rp 109 Rp 218,000
32 Acetosal 100 mg Tablet 16TB002 - Agust-18 Rp 134 Rp -
34 Acyclovir krim tube 5 g Tube 55305001BA - Rp 3,148 Rp -
35 Acyclovir tab 200 mg Tablet 1605009 - 6/1/2021 Rp 261 Rp -
36 Acyclovir tab 400 mg Tablet dg0800j - Apr-21 Rp 360 Rp -
41 GKL9912700129Betametason Cream Tube 650770T 48 Jun-18 Rp 1,407 Rp 67,536
42 Bisacodil 10 mg Suppos PL9911 - Jul-17 Rp 6,045 Rp -
43 Cefixime kapsul 100 mg Kapsul PG048037 - Jul-19 Rp 626 Rp -
44 Cefixime sirup kering 100 mg/5 ml Botol PH358041 - Aug-18 Rp 7,490 Rp -
45 Cetirizine 10 mg tablet Tablet 603083 - Mar-19 Rp 145 Rp -
48 Deksametason Injeksi 5 mg / ml-1ml Ampul 95337020-1 100 Jul-19 Rp 1,580 Rp 158,000
49 GKL0133202910Deksametason 0,5 mg Tablet 00714L0040 - Dec-17 Rp 64 Rp -
53 Diazepam 5 mg Tablet 100 Rp 122 Rp 12,200
57 GKL1234010410Domperidon tablet 10 mg Tablet 140807149 - Aug-18 Rp 118 Rp -
62 Eritromosin kaplet 500 mg Kaplet t2214af 1,000 Dec-19 Rp 751 Rp 751,000
64 Eritromosin sirup 200 mg/ml botol - Rp 7,893 Rp -
72 Fenobarbital 30 mg Tablet 1502005 - Apr-20 Rp 260 Rp -
PKM SEMERAP 2016 9

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
76 Fitomenadion 10 mg Tablet 95381002 500 Apr-19 Rp 730 Rp 365,000
78 Garam Oralit Kombinasi Sachet 95373609CC - Sep-19 Rp 269 Rp -
85 Glukosa Lar. 10 % Infus Botol 230916 - Agt-18 Rp 7,500 Rp -
86 Glukosa Lar. 5 % Infus Botol 220724 - Jul-17 Rp 6,900 Rp -
88 Haloperidol 0,5 mg Tablet 1606121 500 6/1/2019 Rp 62 Rp 31,000
89 Haloperidol 1,5 mg Tablet 1609127 - Sep-19 Rp 71 Rp -
93 Hidrokortison Cream Tube 660772T - Feb-20 Rp 2,650 Rp -
95 Hyocine-N-Butilbromide inj 20 mg/ml Ampul 5G0328 - Jul-18 Rp 4,725 Rp -
96 Ibuprofen 200 mg Tablet 160501177 300 5/31/2020 Rp 108 Rp 32,400
97 Ibuprofen 400 mg Tablet AF911921 1,000 Jun-20 Rp 130 Rp 130,000
101 Kaptopril tablet 12.5 mg Tablet 9532300 - Sep-21 Rp 63 Rp -
102 Kaptopril tablet 25 mg Tablet 95324020 - Agust-21 Rp 71 Rp -
106 Kloramfenikol salep Mata 1 % Tube 036007w 24 Mar-19 Rp 1,800
107 Kloramfenikol tetes Mata 0,5% Botol 90616014 - Des-17 Rp 8,753 Rp -
109 Kloramfenikol suspensi 125 mg/5 ml botol 10 Rp 3,978 Rp 39,780
110 D2020708 Klorfeniramin Maleat ( CTM ) Tablet 1606/01152 5,000 Jan-20 Rp 43 Rp 215,000
113 Klorfromazin HCl 25 mg Tablet 65328006 300 Jan-19 Rp 155 Rp 46,500
115 Kodein HCl 10 mg Tablet ME3128J - Nov-19 Rp 575 Rp -
117 Kotrimoksazol 480 mg Tablet T2106AF - Mar-19 Rp 154 Rp -
118 Kotrimoksazol Suspensi Botol S2078AF - Jun-19 Rp 2,183 Rp -
122 Larutan Eosin 2 % Botol - Rp 139,145 Rp -
131 Lidokain Komp. Injeksi Ampul 95362034-2 100 May-20 Rp 870 Rp 87,000
132 Lisol Botol - Rp 164,488 Rp -
133 Loperamide 2 mg Tablet 50506 500 Jul-18 Rp 87 Rp 43,500
134 Magnesium sulfat injeksi 20% 5-25 ml Ampul 80K45A - Nov-17 Rp 3,200 Rp -
135 Magnesium sulfat injeksi 40 % Ampul 7374J45A - Okt-17 Rp 3,650 Rp -
139 Metil Ergometrin 0,125 mg Tablet 18G250 - Sep-19 Rp 3,115 Rp -
141 Metilprednisolon 4 mg tablet YY002 - 5/30/2019 Rp 202 Rp -
143 Metoklopramid 10 mg tablet WE079A 1,000 May-21 Rp 95 Rp 95,000
145 Metronidazol 500 mg Tablet T1751068 300 Jul-18 Rp 133 Rp 39,900
147 Mikonazol krim/salep 2% (Nitrat) tube 046057W - Apr-20 Rp 3,410 Rp -
149 N-asetilsistein 200 mg kapsul 1605043 - 01/06/18 Rp 447 Rp -
PKM SEMERAP 2016 10

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
151 Natrium Bikarbonat Tablet 1609129 - Sep-20 Rp 39 Rp -
152 Natrium Diklofenak tablet 50 mg Tablet 95365009R 600 3/30/2019 Rp 160 Rp 96,000
153 Natrium Klorida 0,9% Infus Botol 260408 20 Mar-21 Rp 6,410 Rp 128,200
156 Nystatin Tablet Vagina Tablet 95372003 - Rp 160 Rp -
157 OAT Kategori Anak Paket - Rp 225,739 Rp -
158 Obat TB FDC kategori I dewasa Paket - Rp 377,985 Rp -
160 Obat Batuk Hitam ( OBH ) Botol 1510012 - Oct-19 Rp 12,590 Rp -
163 Oksitetrasiklin Salap Mata 1 % Tube 5-51006 - Oct-20 Rp 20,170 Rp -
165 Omeprazol kapsul 20 mg Kapsul HG1835 - Feb-20 Rp 164 Rp -
167 Parasetamol Syrup Botol J19401 - Oct-17 Rp 1,119 Rp -
168 Parasetamol 500 mg Tablet 00814L0070 10,000 Dec-19 Rp 84 Rp 840,000
173 Piridoksin ( Vit. B 6 ) Tablet E160464B - Mei-19 Rp 124 Rp -
174 Piroksikam 20 mg Tablet 160359 - Apr-19 Rp 156 Rp -
177 Propil thio urasil ( PTU ) Tablet 1506010 - Mei-21 Rp 433 Rp -
178 Propanolol 10 mg Tablet - Rp 66 Rp -
185 Salap 2-4 kombinasi Pot 16S042B - Jun-20 Rp 2,554 Rp -
186 Salbutamol tab 4 mg Tablet E150761B - May-20 Rp 83 Rp -
188 Sefotaksim injeksi 1 gram vial - Rp 5,925 Rp -
194 Siprofloksasin 500 mg Tablet 60641108 2,000 6/1/2020 Rp 289 Rp 578,000
195 Spironolakton tablet 100 mg Tablet - Rp 878 Rp -
197 Stesolid-Diazepam larutan rektal 10 mg/2.5 ml Tube R23691715 30 Sep-17 Rp 17,600 Rp 528,000
204 Thiamin HCl 50 mg ( Vit. B 1 ) Tablet - Rp 89 Rp -
210 GBL1312702210Vitamin B komplex Tablet K40644T - Sep-17 Rp 121 Rp -
212 Yodium Povidon 10 % - 60 ml Botol - Rp 6,550 Rp -
213 Yodium Povidon 10 % - 300 ml Botol K18507 2 Nop-18 Rp 39,470 Rp 78,940
214 Zinc tablet 20 mg Tablet 1507093 500 Agust-18 Rp 540 Rp 270,000
OBAT GIGI
3 Etil klorida Semprot Tabung - Rp 168,012 Rp -
PKM SEMERAP 2016 11

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
1 Alat Suntik Sekali Pakai 1 ml Set 810 - Agust-19 Rp 762 Rp -
Alat suntik sekali pakai 10 ml Set - Agust-19 Rp 1,103 Rp -
13 Infusion Set Anak pcs - Rp 4,837 Rp -
15 Infusion Set Dewasa pcs 20 Mar-19 Rp 4,232 Rp 84,640
16 IV Catheter No.18 G pcs - Jun-16 Rp 8,700 Rp -
23 Kassa Pembalut Elastis 15 x 4,55cm Rol - Rp 43,987 Rp -
24 Kassa Pembalut Elastis 10 x 4,55 cm Rol 1510373 - Okt-20 Rp 43,987 Rp -
25 Kassa Pembalut Elastis 3 Inc rol - Rp -
26 Kassa Pembalut Elastis 4 Inc rol - Rp 12,096 Rp -
27 Masker pcs - Oct-20 Rp 647 Rp -
29 Plester 5 yard x 2 inch Rol - Nov-19 Rp 17,685 Rp -
Sungai Penuh,27 Januari 2017

Yang Menyerahkan Yang Menerima
YENNI HASNIARTI,Amd.Farm DEVI FITRIANI DAHRIL

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19660525 198803 1 005
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 12

I. Lampiran III PUSKESMAS PELOMPEK

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
5 Aminopilin 200 mg Tablet T. 2550021 200 Jul-19 Rp 162 Rp 32,400
10 Amoksisilin sirup kering forte 250 mg/5 ml Botol 120 Rp 4,212 Rp 505,440
11 Amoksisilin 250 mg Kapsul 1605/02-051 2,000 5/31/2020 Rp 201 Rp 402,000
PJ018236,PJ0
18237
17 Antasida DOEN Tablet 5549533 5,000 Nov-17 Rp 63 Rp 315,000
18 Antasida Doen Suspensi Botol 155H026 200 Nov-18 Rp 2,065 Rp 413,000
19 Anti Bakteri DOEN salap Tube 1507007 25 Jul-19 Rp 2,641 Rp 66,025
35 Acyclovir tab 200 mg Tablet 1605009 1,000 6/1/2021 Rp 261 Rp 261,000
43 Cefixime kapsul 100 mg Kapsul PG048037 1,000 Jul-19 Rp 626 Rp 626,000
44 Cefixime sirup kering 100 mg/5 ml Botol PH358041 10 Aug-18 Rp 7,490 Rp 74,900
45 Cetirizine 10 mg tablet Tablet 603083 1,000 Mar-19 Rp 145 Rp 145,000
48 Deksametason Injeksi 5 mg / ml-1ml Ampul 95337020-1 - Jul-19 Rp 1,580 Rp -
49 GKL0133202910Deksametason 0,5 mg Tablet 00714L0040 1,000 Dec-17 Rp 64 Rp 64,000
62 Eritromosin kaplet 500 mg Kaplet t2214af - Dec-19 Rp 751 Rp -
72 Fenobarbital 30 mg Tablet 1502005 300 Apr-20 Rp 260 Rp 78,000
PKM SEMERAP 2016 13

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
76 Fitomenadion 10 mg Tablet 95381002 1,000 Apr-19 Rp 730 Rp 730,000
86 Glukosa Lar. 5 % Infus Botol 220724 40 Jul-17 Rp 6,900 Rp 276,000
93 Hidrokortison Cream Tube 660772T 48 Feb-20 Rp 2,650 Rp 127,200
97 Ibuprofen 400 mg Tablet AF911921 600 Jun-20 Rp 130 Rp 78,000
133 Loperamide 2 mg Tablet 50506 1,000 Jul-18 Rp 87 Rp 87,000
139 Metil Ergometrin 0,125 mg Tablet 18G250 200 Sep-19 Rp 3,115 Rp 623,000
141 Metilprednisolon 4 mg tablet YY002 1,000 5/30/2019 Rp 202 Rp 202,000
145 Metronidazol 500 mg Tablet T1751068 1,000 Jul-18 Rp 133 Rp 133,000
147 Mikonazol krim/salep 2% (Nitrat) tube 046057W 48 Apr-20 Rp 3,410 Rp 163,680
PKM SEMERAP 2016 14

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
152 Natrium Diklofenak tablet 50 mg Tablet 95365009R 2,800 3/30/2019 Rp 160 Rp 448,000
156 Nystatin Tablet Vagina Tablet 95372003 100 Rp 160 Rp 16,000
160 Obat Batuk Hitam ( OBH ) Botol 1510012 288 Oct-19 Rp 12,590 Rp 3,625,920
165 Omeprazol kapsul 20 mg Kapsul HG1835 300 Feb-20 Rp 164 Rp 49,200
167 Parasetamol Syrup Botol J19401 336 Oct-17 Rp 1,119 Rp 375,984
177 Propil thio urasil ( PTU ) Tablet 1506010 500 Mei-21 Rp 433 Rp 216,500
178 Propanolol 10 mg Tablet 1,000 Rp 66 Rp 66,000
180 Ranitidin 10 mg Tablet 4GE4123 3,000 Aug-17 Rp 115 Rp 345,000
186 Salbutamol tab 4 mg Tablet E150761B 500 May-20 Rp 83 Rp 41,500
204 Thiamin HCl 50 mg ( Vit. B 1 ) Tablet 3,000 Rp 89 Rp 267,000
210 GBL1312702210Vitamin B komplex Tablet K40644T 5,000 Sep-17 Rp 121 Rp 605,000
214 Zinc tablet 20 mg Tablet 1507093 - Agust-18 Rp 540 Rp -
OBAT GIGI
4 Eugenol Cairan Botol - Rp 19,005 Rp -
PKM SEMERAP 2016 15

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
9 Foley Catheter 18 fr pcs 21H15 50 Jun-20 Rp 18,450 Rp 922,500
15 Infusion Set Dewasa pcs - Mar-19 Rp 4,232 Rp -
16 IV Catheter No.18 G pcs - Rp 8,700 Rp -
24 Kassa Pembalut Elastis 10 x 4,55 cm Rol 1510373 5 Okt-20 Rp 43,987 Rp 219,935
29 Plester 5 yard x 2 inch Rol 12 Nov-19 Rp 17,685 Rp 212,220

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI FORAMIKI SASEDE, AMF

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19870804 201101 2 005
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 16

I. Lampiran III PUSKESMAS KERSIK TUO

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
3 Ambroxol sirup 15 mg/ml Botol 1603026 - Mar-19 Rp 4,520 Rp -
5 Aminopilin 200 mg Tablet T. 2550021 1,000 Jul-19 Rp 162 Rp 162,000
PJ018236,PJ0
18237
25 GBL9514103110Asam Folat tab 1 mg Tablet 681603153 400 Mar-18 Rp 50 Rp 20,000
36 Acyclovir tab 400 mg Tablet dg0800j 1,500 Apr-21 Rp 360 Rp 540,000
43 Cefixime kapsul 100 mg Kapsul PG048037 300 Jul-19 Rp 626 Rp 187,800
57 GKL1234010410Domperidon tablet 10 mg Tablet 140807149 500 Aug-18 Rp 118 Rp 59,000
58 Domperidon Suspensi 5 mg/5 ml btl 60 ml 150709149 - Jul-19 Rp 3,410 Rp -
62 Eritromosin kaplet 500 mg Kaplet t2214af 500 Dec-19 Rp 751 Rp 375,500
PKM SEMERAP 2016 17

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
96 Ibuprofen 200 mg Tablet 160501177 1,000 5/31/2020 Rp 108 Rp 108,000
PKM SEMERAP 2016 18

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
177 Propil thio urasil ( PTU ) Tablet 1506010 2,000 Mei-21 Rp 433 Rp 866,000
187 Salisil bedak Kotak 114237 - Nov-17 Rp 1,046 Rp -
OBAT GIGI
PKM SEMERAP 2016 19

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
13 Infusion Set Anak pcs 100 Rp 4,837 Rp 483,700

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI VICA KURNIA MAYA,AMF

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19841008 201001 2 023
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 20

I. Lampiran III PUSKESMAS GUNUNG LABU

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
9 Amoksisilin Dry Syrup 125mg/5ml Botol 1509-16-96 50 Sep-18 Rp 2,500 Rp 125,000
PJ018236,PJ0
12 Amoksisilin 500 mg Kaplet 18237 5,000 Jul-19 Rp 233 Rp 1,165,000
21 Anti Fungi DOEN salap Pot 15A02 - Feb-20 Rp 1,982 Rp -
43 Cetirizine 10 mg tablet Tablet 603083 300 Mar-19 Rp 145 Rp 43,500
51 Diazepam 5 mg Tablet - Rp 122 Rp -
PKM SEMERAP 2016 21

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
94 Ibuprofen 200 mg Tablet 160501177 - 5/31/2020 Rp 108 Rp -
104 Kloramfenikol salep Mata 1 % Tube 036007w - Mar-19 Rp 1,800
107 Kloramfenikol suspensi 125 mg/5 ml botol - Rp 3,978 Rp -
111 Klorfromazin HCl 25 mg Tablet 65328006 1,000 Jan-19 Rp 155 Rp 155,000
124 Larutan HCl 0,1 % Botol 50 ml 5 Rp 9,313 Rp 46,565
141 Metoklopramid 10 mg tablet WE079A - May-21 Rp 95 Rp -
PKM SEMERAP 2016 22

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
214 Zinc sir 20 mg/5ml Botol 60 ml 12 Rp 7,770 Rp 93,240
OBAT GIGI
PKM SEMERAP 2016 23

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
16 IV Catheter No.18 G pcs 40 Jun-16 Rp 8,700 Rp 348,000
23 Kassa Pembalut Hidropil 4 x 10 cm Rol - Rp -
25 Kassa Pembalut Elastis 10 x 4,55 cm Rol 1510373 5 Okt-20 Rp 43,987 Rp 219,935
26 Masker pcs 100 Oct-20 Rp 647 Rp 64,700

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI RITA LESTARI,S.Farm

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19790710 201101 2 005
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 24

I. Lampiran III PUSKESMAS SIULAK MUKAI

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0
18237
36 Acyclovir tab 400 mg Tablet dg0800j 3,000 Apr-21 Rp 360 Rp 1,080,000
PKM SEMERAP 2016 25

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
132 Lisol Botol 3 Rp 164,488 Rp 493,464
PKM SEMERAP 2016 26

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
188 Sefotaksim injeksi 1 gram vial 20 Rp 5,925 Rp 118,500
197 Stesolid-Diazepam larutan rektal 10 mg/2.5 ml Tube R23691715 - Sep-17 Rp 17,600 Rp -
OBAT GIGI
PKM SEMERAP 2016 27

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI FERIALDI,SKM

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP.19750207 200604 1 004
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 28

I. Lampiran III PUSKESMAS SIULAK DERAS

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0
18237
19 Anti Bakteri DOEN salap Tube 1507007 - Jul-19 Rp 2,641 Rp -
29 Vitamin C 50 mg Tablet F151006B - Jun-18 Rp 109 Rp -
60 Efinefrin Injeksi Ampul 653440092 - Rp 8,505 Rp -
PKM SEMERAP 2016 29

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
88 Haloperidol 0,5 mg Tablet 1606121 - 6/1/2019 Rp 62 Rp -
113 Klorfromazin HCl 25 mg Tablet 65328006 - Jan-19 Rp 155 Rp -
PKM SEMERAP 2016 30

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
152 Natrium Diklofenak tablet 50 mg Tablet 95365009R - 3/30/2019 Rp 160 Rp -
OBAT GIGI
PKM SEMERAP 2016 31

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
17 IV Catheter No.18 G pcs - Rp 8,700 Rp -

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI YOSNIDA ELITA,Amd.Farm

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP.198001 200802 2 001
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 32

I. Lampiran III PUSKESMAS SIULAK GEDANG

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0 10,000 Rp 2,330,000
12 Amoksisilin 500 mg Kaplet Jul-19 Rp 233
18237
PKM SEMERAP 2016 33

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
122 Larutan Eosin 2 % Botol 1 Rp 139,145 Rp 139,145
133 Loperamide 2 mg Tablet 50506 - Jul-18 Rp 87 Rp -
PKM SEMERAP 2016 34

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
204 Thiamin HCl 50 mg ( Vit. B 1 ) Tablet 500 Rp 89 Rp 44,500
OBAT GIGI
PKM SEMERAP 2016 35

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI ILUS ELVIA

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19800622 200604 2 014
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 36

I. Lampiran III PUSKESMAS SEMURUP

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0
18237 10,000 Rp 2,330,000
PKM SEMERAP 2016 37

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
139 Metil Ergometrin 0,125 mg Tablet 18G250 500 Sep-19 Rp 3,115 Rp 1,557,500
PKM SEMERAP 2016 38

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
163 Oksitetrasiklin Salap Mata 1 % Tube 5-51006 14 Oct-20 Rp 20,170 Rp 282,380
OBAT GIGI
3 Etil klorida Semprot Tabung 2 Rp 168,012 Rp 336,024
PKM SEMERAP 2016 39

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
17 IV Catheter No.18 G pcs 3113777 20 Nov-20 Rp 8,700 Rp 174,000
18 IV Catheter No.20 G pcs 3034019 - Jul-20 Rp 8,700 Rp -
19 IV Catheter No.22 G pcs 3059137 - Nov-20 Rp 8,700 Rp -
20 IV Catheter No.24 G pcs 3034038 - Sep-20 Rp 8,700 Rp -

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI MARISCA YOSEVINA,AM.Farm

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP.19900415 201101 2 001
Mengetahui
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 40

I. Lampiran III PUSKESMAS KEMANTAN

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0 10,000 Rp 2,330,000
12 Amoksisilin 500 mg Kaplet 18237 Jul-19 Rp 233
PKM SEMERAP 2016 41

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
95 Hyocine-N-Butilbromide inj 20 mg/ml Ampul 5G0328 100 Jul-18 Rp 4,725 Rp 472,500
106 Kloramfenikol salep Mata 1 % Tube 036007w 24 Mar-19 Rp 1,800 Rp 43,200
110 D2020708 Klorfeniramin Maleat ( CTM ) Tablet 1606/01152 - Jan-20 Rp 43 Rp -
132 Lisol Botol 3 Rp 164,488 Rp 493,464
PKM SEMERAP 2016 42

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
OBAT GIGI
PKM SEMERAP 2016 43

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI RINA SOFYARTI,AM.Farm

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP.19740319 199802 2 004
Mengetahui
Plt. Kepala Gudang Farmasi
HARLIS,S.Farm,Apt
NIP. 19760804 199703 1 003
PKM SEMERAP 2016 44

I. Lampiran III PUSKESMAS DEPATI TUJUH

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0 5,000 Rp 1,165,000
18237
17 Antasida DOEN Tablet 5549533 - Nov-17 Rp 63 Rp -
35 Acyclovir tab 200 mg Tablet 1605009 700 6/1/2021 Rp 261 Rp 182,700
36 Acyclovir tab 400 mg Tablet dg0800j 300 Apr-21 Rp 360 Rp 108,000
PKM SEMERAP 2016 45

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
76 Fitomenadion 10 mg Tablet 95381002 Apr-19 Rp 730 Rp -
106 Kloramfenikol salep Mata 1 % Tube 036007w - Mar-19 Rp 1,800 Rp -
132 Lisol Botol 1 Rp 164,488 Rp 164,488
145 Metronidazol 500 mg Tablet T1751068 - Jul-18 Rp 133 Rp -
PKM SEMERAP 2016 46

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
213 Yodium Povidon 10 % - 300 ml Botol K18507 - Nop-18 Rp 39,470 Rp -
OBAT GIGI
PKM SEMERAP 2016 47

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI RAHMI NURHIDAYATI,A.MF

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19830614 200902 2 004
Mengetahui
DEWI KASMITA,S.Farm,Apt
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 48

I. Lampiran III PUSKESMAS SUNGAI TUTUNG

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0 1,000 Rp 233,000
18237
43 Cefixime kapsul 100 mg Kapsul PG048037 1,000 Jul-19 Rp 626 Rp 626,000
PKM SEMERAP 2016 49

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PKM SEMERAP 2016 50

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
158 Obat TB FDC kategori I dewasa Paket 1 Rp 377,985 Rp 377,985
195 Spironolakton tablet 100 mg Tablet 500 Rp 878 Rp 439,000
214 Zinc tablet 20 mg Tablet 1507093 1,000 Agust-18 Rp 540 Rp 540,000
OBAT GIGI
PKM SEMERAP 2016 51

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
16 IV Catheter No.18 G pcs 10 Nov-20 Rp 8,700 Rp 87,000

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI NOPALENI MARLINA,AM,Kep

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19840609 201101 2 004
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 52

I. Lampiran III PUSKESMAS HIANG

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
3 Ambroxol sirup 15 mg/ml Botol 1603026 500 Mar-19 Rp 4,520 Rp 2,260,000
6 GKL8713603943Aminopilin Injeksi 24 mg /ml-10ml Ampul 1411015 60 Sep-18 Rp 4,013 Rp 240,780
7 GKL8920905817Amitriptilin 25 mg Tablet 1503002 100 Mar-19 Rp 117 Rp 11,700
PJ018236,PJ0
18237
18 Antasida Doen Suspensi Botol 155H026 500 Nov-18 Rp 2,065 Rp 1,032,500
60 Efinefrin Injeksi Ampul 653440092 - Rp 8,505 Rp -
PKM SEMERAP 2016 53

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PKM SEMERAP 2016 54

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
OBAT GIGI
PKM SEMERAP 2016 55

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI JUAIRIAH

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19700224 1997103 2 004
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 56

I. Lampiran III PUSKESMAS SANGGARAN AGUNG

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0 5,000 Rp 1,165,000
18237
PKM SEMERAP 2016 57

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
132 Lisol Botol 1 Rp 164,488 Rp 164,488
141 Metilprednisolon 4 mg tablet YY002 300 5/30/2019 Rp 202 Rp 60,600
PKM SEMERAP 2016 58

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
153 Natrium Klorida 0,9% Infus Botol 260408 - Mar-21 Rp 6,410 Rp -
-
OBAT GIGI -
PKM SEMERAP 2016 59

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI MAULIAH,S.Kep

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19800130 201001 2 010
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 60

I. Lampiran III PUSKESMAS TARURUNG

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0
18237
25 GBL9514103110Asam Folat tab 1 mg Tablet 681603153 500 Mar-18 Rp 50 Rp 25,000
PKM SEMERAP 2016 61

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PKM SEMERAP 2016 62

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
152 Natrium Diklofenak tablet 50 mg Tablet 95365009R 500 3/30/2019 Rp 160 Rp 80,000
OBAT GIGI
PKM SEMERAP 2016 63

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI HILMAN,SKM

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 197001003 199703 1 013
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 64

I. Lampiran III PUSKESMAS TAMIAI

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0
12 Amoksisilin 500 mg Kaplet 18237 6,000 Jul-19 Rp 233 Rp 1,398,000
20 Anti Haemoroid suppos Suppos A5013 - Jan-19 Rp 3,197 Rp -
21 Anti Fungi DOEN salap Pot 15A02 - Feb-20 Rp 1,982 Rp -
PKM SEMERAP 2016 65

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
76 Fitomenadion 10 mg Tablet 95381002 - Apr-19 Rp 730 Rp -
PKM SEMERAP 2016 66

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
OBAT GIGI
PKM SEMERAP 2016 67

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI ADRIANI,Amd.Kep

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19680712 198803 2 002
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 68

I. Lampiran III PUSKESMAS LOLO

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PJ018236,PJ0
18237 10,000 Rp 2,330,000
62 Eritromosin kaplet 500 mg Kaplet t2214af 1,000 Dec-19 Rp 751 Rp 751,000
PKM SEMERAP 2016 69

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PKM SEMERAP 2016 70

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
168 Parasetamol 500 mg Tablet 00814L0070 - Dec-19 Rp 84 Rp -
194 Siprofloksasin 500 mg Tablet 60641108 - 6/1/2020 Rp 289 Rp -
OBAT GIGI
PKM SEMERAP 2016 71

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI HARMINTO,AMK

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19651223 201408 1 002
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 72

I. Lampiran III PUSKESMAS LEMPUR

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
12 Amoksisilin 500 mg Kaplet PJ018236,PJ Jul-19 Rp 233
10,000 Rp 2,330,000
018237
PKM SEMERAP 2016 73

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
PKM SEMERAP 2016 74

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
OBAT GIGI
PKM SEMERAP 2016 75

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
16 Infusion Set Dewasa pcs 300 Mar-19 Rp 4,232 Rp 1,269,600

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI SILVIA EKA WATI,SKM

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19790312 200502 2 001
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 76

I. Lampiran III PUSKESMAS JUJUN

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
3 Ambroxol sirup 15 mg/ml Botol 1603026 300 Mar-19 Rp 4,520 Rp 1,356,000
PJ018236,PJ0
12 Amoksisilin 500 mg Kaplet - Jul-19 Rp 233 Rp -
18237
PKM SEMERAP 2016 77

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
95 Ibuprofen 400 mg Tablet AF911921 - Jun-20 Rp 130 Rp -
147 N-asetilsistein 200 mg kapsul 1605043 600 01/06/18 Rp 447 Rp 268,200
PKM SEMERAP 2016 78

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
-
OBAT GIGI -
PKM SEMERAP 2016 79

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
-
PERBEKALAN KESEHATAN -

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI WIDYAWATI

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP.19730727 199703 2 004
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 80

I. Lampiran III PUSKESMAS SEMERAP

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
6 GKL8713603943 A Aminopilin Injeksi 24 mg /ml-10ml Ampul 1411015 - Sep-18 Rp 4,013 Rp -
7 GKL8920905817A1Amitriptilin 25 mg Tablet 1503002 - Mar-19 Rp 117 Rp -
12 Amoksisilin 500 mg Kaplet PJ018236,PJ0 Jul-19 Rp 233
3,000 Rp 699,000
18237
25 GBL9514103110A1Asam Folat tab 1 mg Tablet 681603153 - Mar-18 Rp 50 Rp -
35 GKL9520906143B1Atropin Sulfat Injeksi 0,25 mg/ml-1ml Ampul 1304005 - Apr-18 Rp 1,291 Rp -
39 GKL9912700129A1Betametason Cream Tube 650770T 48 Jun-18 Rp 1,407 Rp 67,536
47 GKL0133202910A1Deksametason 0,5 mg Tablet 00714L0040 - Dec-17 Rp 64 Rp -
55 GKL1234010410A1Domperidon tablet 10 mg Tablet 140807149 - Aug-18 Rp 118 Rp -
PKM SEMERAP 2016 81

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
81 GBL1025803510A1Gliseril Guayakolat 100 mg Tablet 1502150 - Feb-18 Rp 125 Rp -
91 Hidrokortison Cream Tube 660772T - Feb-20 Rp 2,650 Rp -
104 Kloramfenikol Salep Mata 1 % Tube 036007w 48 Mar-19 Rp 1,800 Rp 86,400
129 Lidokain Komp. Injeksi Ampul 95362034-2 - May-20 Rp 870 Rp -
PKM SEMERAP 2016 82

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
166 Parasetamol 500 mg Tablet 00814L0070 - Dec-19 Rp 84 Rp -
169 GNL7212416643A1Pethidin HCl Injeksi 50 mg/ml-2ml Ampul ID 1596J - Agt-19 Rp 15,225 Rp -
208 GBL1312702210A1Vitamin B komplex Tablet K40644T 9,400 Sep-17 Rp 121 Rp 1,137,400
OBAT GIGI
PKM SEMERAP 2016 83

( Rp )
1 2 3 4 5 6 7 8 9=6x8 10
23 Kassa Pembalut Hidropil 40 y x 80 cm Rol - Rp 149,987 Rp -

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI DEFIE SETIAWATI, AM.Farm

NIP. 19790917 201001 2 018 NIP. 19830711 200701 2 001 NIP. 19771222 199603 2 001
Mengetahui
NIP. 19800409 200804 2 001
PKM SEMERAP 2016 84

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Lampiran III JML OBAT KELUAR TRI I

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 1

PKM SEMERAP 2016 2

PKM SEMERAP 2016 3

Sungai Penuh,01 Maret 2017

PKM SEMERAP 2016 4

PKM SEMERAP 2016 5

PKM SEMERAP 2016 6

PKM SEMERAP 2016 7

PKM SEMERAP 2016 8

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 9

PKM SEMERAP 2016 10

PKM SEMERAP 2016 11

Sungai Penuh,27 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI DAHRIL

PKM SEMERAP 2016 12

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 13

PKM SEMERAP 2016 14

PKM SEMERAP 2016 15

Sungai Penuh,26 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI FORAMIKI SASEDE, AMF

PKM SEMERAP 2016 16

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 17

PKM SEMERAP 2016 18

PKM SEMERAP 2016 19

Sungai Penuh,25 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI VICA KURNIA MAYA,AMF

PKM SEMERAP 2016 20

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 21

PKM SEMERAP 2016 22

PKM SEMERAP 2016 23

Sungai Penuh,24 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI RITA LESTARI,S.Farm

PKM SEMERAP 2016 24

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 25

PKM SEMERAP 2016 26

PKM SEMERAP 2016 27

Sungai Penuh,23 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI FERIALDI,SKM

PKM SEMERAP 2016 28

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 29

PKM SEMERAP 2016 30

PKM SEMERAP 2016 31

Sungai Penuh,20 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI YOSNIDA ELITA,Amd.Farm

PKM SEMERAP 2016 32

NAMA OBAT JLH DISTR HARGA

PKM SEMERAP 2016 33

PKM SEMERAP 2016 34

PKM SEMERAP 2016 35

Sungai Penuh,19 Januari 2017

YENNI HASNIARTI,Amd.Farm DEVI FITRIANI ILUS ELVIA

PKM SEMERAP 2016 36

NAMA OBAT JLH DISTR HARGA