SURAT PESANAN OBAT-OBAT TERTENTU

Yang bertanda tangan di bawah ini :

Nama : Siti Korimah, S.Farm.,Apt
Jabatan : Apoteker Apotek
No. SIPA : 111/0111/1234/1-20

Mengajukan pesanan obat-obat tertentu kepada :

Nama distributor :Anugrah Argon Medica

Alamat : Jl. AKBP Cak Agus No.6534 RT.49 / RW.08, Llir Timur II, 8 Ilir, Kec.
Ilir Tim. II, Kota Palembang, Sumatera Selatan 30163

No. Bentuk jumlah ket

Nama sediaan kandungan /kekuatan
sediaan
1 - Hyoscine N-butyl
bromide 10 mg
Scopamin plus Tablet 4
- Paracetamol 500
mg

2 - Hyoscine N-butyl
bromide 10 mg
Spasmacine Tablet 5
- Paracetamol 500
mg

3 - Papaverin hcl 25
mg
Spasminal Tablet 6
- Belladonna
extract 10 mg

4 - Hyoscine N-butyl
Spasmolit Tablet 10
bromide 10 mg

5 - Hyoscine N-butyl
bromide 10 mg 10
Unthecol Tablet

6 Scopamin
- Hyoscine N-butyl
Ampul 2
Injeksi bromide 20mg/ml
7 - Hyoscine N-butyl
Buscopan injeksi Ampul 3
bromide 20mg/ml

8 - Levothyeroxine
Euthyrox Tablet 10
sodium 100mg

9 Prophylthiourasi
- Prophylthiourasil
Tablet 8
l 100mg 100mg

10 - Thiamazolet
Thyrozol Tablet 12
10mg

11 Benocetam - Piracetam 400 mg Tablet 10

12 - Mecobalamin
Berthyco Kapsul 5
500mg

13 - Mecobalamin
Mecobalamin Kapsul 6
500mg

14 - Mecobalamin
Mobafer Kapsul 4
500mg

15 - Mecobalamin
Nufacobal Kapsul 3
500mg

16 Piracetam - Piracetam 400 mg Tablet 10

17 - Vit B1 50mg

- Vit B 2 25mg

- Vit B6 10mg

- Vit B12 5mcg

- Nikotinamide 5
Ascoplex Kaplet
100mg

- Kalsium
Pantotenat 25 mg

- Asam Folat 0,5mg

- Vit C 175mg

18 - Astaxanthin 4mg Kapsul 5

Astria
lunak
19 Bexicom Z - Vit B1 15mg Kaplet 5

- Vit B2 15mg
 - Vit B6 20mg

- Calcium
Panthothenate
100mg

- Nicotinamide
100mg

- Vit B12 12mcg

- Folic Acid 40MG

Vit C 750mg

- Vit E 30 mg Zinc
Sulfate 98,9mg

- Eurolake
Erythrocine

20 - Adenosine
triphosphate
20mg

- Thiamine 100 mg

- Pyridoxine Hcl
Tablet salut 10
bio ATP 200mg film
- Cyanocobalamin
200mcg

- Alpha tocopherol
30 mg

21 Bionemi - Fe Gluconat Kapsul 5

250mg

- Asam Folat
400mg

- Copper Sulfat
200mcg

- Mangan Sulfat
200mcg

- Bit B12 7,5mcg

- Vit C 50mg
 - Sorbitol 25mg

22 - Vit C 300 mg

- Ext Citrus 5
Cester Kaplet
Bioflavonoid
100mg

23 - Omega-3-acid ethyl
esters 90% 1 g
Kapsul 5
Cormega - EPA min 440 mg lunak
- DHA min 370 mg

24 - Fe
Phyrophosphate
175mg

- Mangan Sulfat
100mcg

- Cupri Sulfat Tablet 3

Ferosat
effervescent
100mcg

- Vit C 50mg

- Asam Folat 0,5mg

- Vit B12 7,5 mcg

25 - Echinacea
Purpurea Extract
500MG

- β1,3/1,6 Glucan
175mg

Imunos Plus Kaplet 5

- Zn Picolinate
10mg

- Selenium 15mcg

- Asam askorbat 50
mg

26 Ketocid - Calcium-3 methyl Kaplet salut 4

oxo-valerate 67 selaput
mg

- Calcium-4 methyl
oxo-valerate 101
 mg

- Calcium-2- oxo-3-
phenylpropionate
68 mg

- Calcium-3 methyl-
2-oxo-butyrate 86
mg

- Calcium-DL-2-
hydroxy-4-
butyrate 59 mg

- L-Lysine-acetate
105 mg

- L-threonine 53 mg

- L-tryptophan 23
mg

- L-histidine 38 mg

- L-tyrosine 30 mg

27 - Lecithin murni (PPC

95%) 175 mg (300 mg
untuk Lesichol-300 & 600
mg untuk Lesichol-600)

- vit B1 6 mg

- vit B2 6 mg Kapsul 3
Lesicol 300
lunak
- vit B6 6 mg

- vit B12 6 mcg

- vit E 10 mg

- nicotinamide 30 mg

28 Optalvit plus - Ekstr kering Tablet

Billberry 80 mg

- retinol 1.600 IU

- β-carotene 5 mg

- vit E 50 mg
 - lutein 250 mcg

- zeaxanthin 67
mcg

- selenium 15 mcg

- Zn sulfate 5 mg

29 - Chana Striata
Posafit Purified Extract Tablet 4
250mg

30 - Coenzym Q10 60
mg

- Vit C 50 mg
Q10 plus Kapsul
- Zingiber officinale
rhizome extract
50 mg

31 - Vit B1 100MG

Rindobion - Vit B6 200mg Kaplet salut 2

selaput
- Vit B12 200mg

32 - Commiphora wightii
bubuk 0.162g

- Shankha bhasma 32
mg

- Maharasnadi quath
ekstr 65 mg

- Tinospora cordifolia
49 mg
Septilin Tablet 2
- Rubia cardilfolia 32
mg

- Emblica officinalis 16
mg

- Moringa
pterygosperma 16 mg

- Glycyrrhiza glabra 6
mg
33 - Red Yeast Rice
Extract 300mg
Trombufit Sachet 4
- Guava Folium
Extract 300mg

34 - Multivitamin

- Minerals
Ultravita Kaplet salut 20
- Lycopene selaput

- Folic Acid

35 - Vit B1 5mg

- Vit B2 2mg

- Vit B3 20mg
Becombion Syrup Sirup 4
- Vit B5 3mg

- Vit B6 2,5 mcg

- Vit B12 3mcg

36 Caviplex syrup + - Vitamin A Sirup 4

DHA palmitate 5000 IU

- Nicotinamide 10
mg

- Vitamin D 400 IU
DHA 10 mg

- Vitamin B1 3 mg

- Ca. Pantothenate
3 mg

- Vitamin B2 1,5 mg

- Ca. Lactate 200

mg

- Vitamin B6 1 mg

- Ca.
Glycerophosphate
100 mg

- Vitamin B12 2,5

 mcg

- L-Glutamic Acid
50 mg

- L-Lysin HCl 100

mg

- Folic acid 30 mcg

37 - sodium
ferederate 115.4
Ferriz sirup 100 ml yang setara Sirup 5
dengan 15 mg
besi elemen

38 - Echinacea
Purpurea Extract
500MG

Imunos plus rasa - β1,3/1,6 Glucan

Sirup 5
jeruk 125mg

- Zn Picolinate 5mg

- Selenium 15mcg

39 - Kurkuminoid 2 mg

- Lysine hcl 250 mg

- Vit B1 3 mg

- Vit B2 2 mg
Kitavit - Vit B6 5 mg Sirup 5

- Vit B12 5 mcg

- Niacinamid 5 mg

- Asam pantotenat
3 mg

40 Mixaria - Vit A 400 mcg Sirup 5

- vit D 5 mcg

- vit E 5 mg

- vit C 60 mg
 - vit B1 0.5 mg

- vit B2 0.5 mg

- vit B3 6 mg

- vit B6 0.5 mg

- vit B12 0.9 mcg

- folic acid 150 mcg

- Fe 10 mg

- Zn 4.1 mg

- copper 0.34 mg

- selenium 17 mcg

- iodine 90 mcg

- vit K 90 mcg

41 - Vitamin A 5000 IU

- Vitamin D 400 IU

- VItamin B1 1 mg

- Vitamin B2 1,2 mg
San B-Plex
multivitamin - Vitamin B6 1 mg 6
Sirup
pediatric drops
- Nicotinamida 10
mg

- Dekspantenol 5
mg

- Vitamin C 50 mg

42 - Fe polymaltose
complex 23.53 mg
(setara elemen
Perifas Sirup 5
besi 8 mg)

- folic acid 80 mcg

43 Sangobion baby - Ferrazone 113 Sirup 5

15 ml mg, setara
dengan elemental
 zat besi 15 mg.

- Vitamin B1 1,0 mg

- Vitamin B2 1,0 mg

- Vitamin B6 1,5 mg

- Vitamin B3 15 mg

- Vitamin B7 0,3 mg

44 - gula

- air

- perisa identic
alami jeruk

Sangobion Kids 5 - pengental

ml syrup natrium Sirup
karboksimetil
selulosa

- natrium benzoate

- pewarna kuning
FCF CI 15985

45 - gula

- air

- perisa identic
alami jeruk

- pengental
Siruplus 100 ml natrium
Sirup 5
rasa jeruk karboksimetil
selulosa

- natrium benzoate

- pewarna
makanan karmoisi
(merah allura)

46 Bartolium 10 - Flunarizine 10mg Tablet 5

47 - Betahistine
Betahistine Tablet 5
Mesilate 6mg
48 Cinnarizine - Cinnarizine 25 mg Tablet 10

49 Dimenhidrinat - Dimenhidrinat
Tablet
50mg 50mg 5

50 Flunarizine - Flunarizin 5mg Tablet 6

51 - Betahistine
Histigo Tablet
Mesilate 6mg 5

52 - Betahistine
Mertigo Tablet
Mesilate 6mg 10

53 Silum 5 - Cinnarizine 25 mg Tablet 10

54 Sinral 5 - Flunarizin 5mg Tablet 8

55 Vercure - Flunarizin 5mg Tablet 10

56 - Betahistine
Vertikaf Tablet
Mesilate 6mg 6

57 - Betahistine
Vertizine Tablet
Mesilate 8 mg 5

58 - Atorvastatin
Atorvastatin 20 Tablet
calcium 20 mg 5

59 - Atorvastatin
Atorvastatin 40 Tablet
calcium 40 mg 5

60 Esvat 10 mg - Simvastatin 10 mg Tablet 6

61 Esvat 20 mg - Simvastatin 20 mg Tablet 7

62 - Atorvastatin
Fastor Tablet 6
calcium 20 mg

63 - Gemfibrozil 300
Gemfibrozil Tablet 10
mg

64 - Gemfibrozil 300
Hypofil Tablet 10
mg

65 - Gemfibrozil 600
Lapibroz Tablet 6
mg

66 - Atorvastatin
Lipitor 20 Tablet 10
calcium 20 mg

67 - Atorvastatin
Lipitor 40 Tablet 5
calcium 40 mg

68 Lotorcom 40 - Atorvastatin Tablet 6

 calcium 40 mg

69 - Pravastatin
Pravinat 20 Tablet 6
sodium 20 mg

70 Simvastatin 10
- Simvastatin 10 mg Tablet 6
mg

71 Simvastatin 20
- Simvastatin 20 mg Tablet 6
mg

72 - Atorvastatin
Stator 20 Tablet 8
calcium 20 mg

73 - Atorvastatin
Stator 40 Tablet 10
calcium 40 mg

74 SVT 10 - Simvastatin 10 mg Tablet 6

75 SVT 20 - Simvastatin 20 mg Tablet 6

76 Actaryl 2 mg - Glimepirid 2 mg Tablet 6

77 - Metformin Hcl
Diafac 500 mg Tablet 10
500 mg

78 - Metformin Hcl
Diaformin xR Kaplet 10
500 mg

79 Diaversa 2 mg - Glimepirid 2 mg Tablet 6

80 - Vildagliptin
Galvusmet 50mg/Metformin Tablet 6
500 mg

81 - Glibenklamid 5
Glibenclamide Tablet 6
mg

82 Glidabet - Gliclazide 80 mg Tablet 6

83 - Metformin Hcl
Gliformin 500 mg Kaplet 6
500 mg

84 Glimepirid - Glimepirid 2 mg Tablet 10

85 Glucophage 1000 - Metformin Hcl

Tablet 6
mg 1000 mg

86 Glucophage 500 - Metformin Hcl

Tablet 6
mg 500mg

87 - Metformin Hcl
500 mg,
Glucovance Tablet 6
Glibenclamid
2,5mg

88 Prodiabet - Glibenklamid 5 Tablet 5

 mg

89 - Metformin Hcl
Metformin Tablet 5
500 mg

90 - Allopurinol 100
Alodan 100 mg Tablet 6
mg

91 - Allopurinol 300
Alodan 300 mg Tablet 6
mg

92 L-cisin - Colchicine 0,5 mg Tablet 3

93 - Probenecid 500 6
Probenid Tablet
mg

94 - Allopurinol 100 5
Reucid 100 mg Tablet
mg

95 - Allopurinol 300 5
Reucid 300 mg Tablet
mg

96 Artem injeksi - Artemether Ampul 6

97 - Dihydratemisinin 5
40 mg
DHP- Frimal Tablet
- Pilperaquin
phospste 320 mg

98 - Chloroquine 6
Malarex phosphate 250 Tablet
mg

99 - Sulfadoksin 4
500mg
Plasmodin Kaplet
- Pyrimethamina
250 mg
100 Constantia 12 ml -Artemether Botol 6

101 Dihydratemisinin 40 mg 10
Ketokonazole
Pilperaquin phospste 320 Tablet
200mg
mg
102 Ketokonazole Chloroquine phosphate 6
Tube
cream 250 mg

103 Ketomed Shampo 4

Sulfadoksin 500mg Botol
60 ml
104 Nystin Artemether Botol 5

105 Miconazole cream Dihydratemisinin 40 mg Cream 6

 - Pilperaquin
phospste 320 mg

106 Chloroquine phosphate 6

Pronazole tab Tablet
250 mg Tablet

10 - Pyrantel pamoat 4
Konvermex 125 Suspense
7 125 mg

10 - Pyrantel pamoat 6
Konvermex 250 Suspense
8 250 mg

10 - Pyrantel pamoat 5
Combatrin 125 Tablet
9 125 mg

11 - Pyrantel pamoat 5
Combatrin 250 Tablet
0 250 mg

11 - Pyrantel pamoat 6
Combatrin 125 Suspense
1 125 mg

11 - Pyrantel pamoat 6
Combatrin 250 Suspense
2 250 mg

11 - Ipratropium 5
3 Bromide 0,52mg
Combivent Nebu Ampul
- Salbutamol sulfat
3,01mg

11 - Salmeterol, 4
4 Flutias Fluticasone Vial
propionate

11 - Procaterol HCL 6
Meptin Tablet
5 0,05mg

11 - Procaterol HCL 6
Meptin Mini Tablet
6 0,025mg

11 - Procaterol HCL 3
Meptin nebu Ampul
7 0,5

11 - Terbutaline Sulfat 5
Nairet Tablet
8 2,5mg

11 - Glyceryl trinitrate 6
Nitral Tablet
9 500mg

12 Pulmicort nebu - Budesonide Ampul 6

0
12 - Theophylline 4
Retaphyl SR Tablet
1 300mg

12 Salbutamol 2 Tablet 10
- Salbutamol 2 mg
2
12 Salbutamol 4 Tablet 10
- Salbutamol 4 mg
3
12 - Salbutamol Sulfat 4
Suprasma Inhaler
4 100mcg

12 - Salbutamol Sulfat 6
Velutine Vial
5 2,5mg

12 Ventoline - Salbutamol Inhaler 5

6
12 - Salbutamol sulfat 4
7 Lasal expectorant 2 mg
Sirup
syrup 100 ml - Guaifenesin 75
mg

12 Lasal syrup 100 5

- Salbutamol 2 mg Sirup
8 ml

12 - Procaterol 6
Meptin syrup 60
9 hydrochloride 50 Sirup
ml
ml

13 Nairet syup 60 - Terbutaline sulfat 4

Sirup
0 ml 1.5 mg

13 Clorilex - Clozapine 25 mg Tablet 6

1
13 - Sertraline hcl 50 3
Fridep 50 Tablet
2 mg

13 Lodomer 5 - Haloperidol 5 mg Tablet 4

3
13 - Chlorpromazine 5
Promactil 100 Tablet
4 hcl 100 mg

13 Forten 25 - Captopril 25 mg Tablet 10

5
13 Forten 50 - Capropril 50 mg Tablet 6
6
13 - Furosemide 40 10
Furosemide Tablet
7 mg

13 Hexavask - Amlodipine 10 mg Tablet 4

8
13 Lotenac - Atenolol 50 mg Tablet 6
9
14 Nifedipine - Nifedipine 10 mg Tablet 5
0
14 Propranolol 40 6
- Propanolol 40 mg Tablet
1 mg

14 Tensivask 5 Tablet 6
- Tensivask 5mg
2
 14 Tensivask 10 Tablet 6
- Tensivask 10mg
3
14 - Candesartan 6
4 cilexcil 8 mg
Unisia Tablet
- Amlodipine
basilate 6.93 mg

14 - Furosemide 40 6
Uresix Tablet
5 mg

14 - Asam asetil 6
Ascardia Tablet
6 salisilat 80 mg

14 - Asam asetil salisat 10

Cartylo Tablet
7 80 mg

14 - Carbazochrome 6
8 Crome sodium sulfat Tablet
10mg

14 Fargoxin - Digoxin 0.25 mg Tablet 10

9
15 - Furosemide 40 10
Farsiretic Tablet
0 mg

15 - Issosorbid dinitrat 10
Farsorbid Tablet
1 10 mg

15 - Potassium 4
2 Kalipar L.aspartate 300 Tablet
mg

15 - Spirinolacton 100 6
Letonal 100 Tablet
3 mg

15 - Clopidogrel base 5
4 75 mg
Medigrel Tablet
- Clopidogrel
bisulfat 75 mg

15 - Tranexamic acid 6
Plasminex Tablet
5 500 mg

15 - Cilostazole 100 6
Pletaal Tablet
6 mg

15 - Spirinolacton 100 10
Spironolacton Tablet
7 mg

Obat-obatan tertentu tersebut digunakan untuk :

Nama :Apotek Farma
Alamat : Jl. Pulau Bangka, Padang Baru, Kec. Pangkalan Baru, Bangka Tengah, Kepulauan
Bangka Belitung
No izin :

Pangkalpinang, 18 maret 2020

Siti Korimah,S.Farm.,Apt
SIPA : 111/0111/1234/1-20