FORM PERMINTAAN OBAT 2019 Form 19rev0

QHSSE - OH/IH

Dikirim ke : COSL 225 Cost Center : G550431 Tanggal : 8-Maret-2019

Material Jumlah Harga per Sub Total
No Deskripsi Nama Obat
Number diminta unit order
5 1 70300164 5 EA - - Abbocath No.18 - Terumo 29,522 147,610 5
1 2 70300022 10 EA 10 per - Adona Inj. Ampoule 2 ml 22,330 223,300 1
1 3 70300021 100 EA 100 per - Adona Tablet 10 mg 2,241 224,100 1
1 4 70300050 1 EA - BOX Anti Bisa Ular (ABU) 5 ml Vial 503,100 503,100 1
1 5 70300111 60 EA 60 per BOX Ardium 500 mg Tablet 7,448 446,880 1
1 6 70300053 100 EA 100 per BOX Atropine 0.25 mg 1 ml Ampoule 2,020 202,000 1
2 7 70300027 2 EA - BOX ATS - Anti Tetanus Serum 1500 Iu 2 ml V 134,550 269,100 2
1 8 70300192 100 EA 100 per BOX Bactrim Forte Tablet 6,056 605,600 1
3 9 700001540 3 EA - BOX Batugin Elixir 300 ml (Colic Pain) 32,792 98,376 3
2 10 70300161 200 EA 100 per BOX Benoson Tablet 0,5 mg 1,444 288,800 2
2 11 70300130 2 EA - BOX Berotec Metered-Dose Inhaler 10 ml 159,477 318,954 2
5 12 700006706 5 BOT - BOX Betadine obat kumur 1%, 190 ml 17,604 88,020 5
2 13 70300136 200 EA 100 per BOX Betadine Plaster 208 41,600 2
6 14 70301033 6 EA - BOX Bioplacenton 15 g Jelly 14,761 88,566 6
1 15 70300032 10 EA 10 per BOX Borraginol-N Suppositoria 9,121 91,210 1
6 16 70301009 6 TU - BOX Burnazine 35 g Cream 49,541 297,246 6
1 17 70300035 12 EA 12 per BOX Caladine 95 ml Lotion 14,727 176,724 1
1 18 70300235 100 TB 100 per - Calcianta 10 mg Tablet 2,553 255,300 1
1 19 70301014 24 EA 24 per BOX Cat Gut Atr.Needle G322T 3/0 64,699 1,552,776 1
3 20 700003292 3 BOX 50 per BOX Cataflam 25 mg Tablet 145,768 437,304 3
6 21 70300151 6 EA - - Cendo Xitrol Ointment 3.5 g 39,036 234,216 6
1 22 70300040 10 EA 10 per BOX Cortidex Inj. 5 mg, 1 ml Ampoule 6,669 66,690 1
1 23 70301105 300 TB 300 per - Dextamine Tablet 2,250 675,000 1
1 24 70300101 30 EA 30 per - Diamicron MR 60 mg Tablet 6,002 180,060 1
1 25 70300036 100 EA 100 per - Dramamine 50 mg Tablet 1,366 136,600 1
1 26 70301039 80 EA 80 per - Dulcolax 5 mg Tablet 1,205 96,400 1
1 27 70300034 1 EA - BOX Ethyl Chloride 100 ml Spray 188,860 188,860 1
3 28 70301122 3 BOX 50 per BOX Face Mask Accurate Disposable, Earloop 29,250 87,750 3
2 29 70301018 240 TB 120 per BOX FG-Troches Meiji 1,020 244,800 2
2 30 70301012 200 EA 100 per BOX Fludane Forte Caplet 782 156,400 2
2 31 70300041 100 EA 50 per BOX Incidal OD 10 mg Capsule 2,544 254,400 2
6 32 70300014 6 EA - BOX Infuse Set, Terumo 15,904 95,424 6
2 33 70300198 120 EA 60 per BOX Lodia 2 mg Tablet 876 105,120 2
1 34 70300163 100 EA 100 per - Merislon 6 mg Tablet 4,242 424,200 1
1 35 700001534 1 BOX 5 per BOX Nairet Inj. 0.5 mg/ml Ampoule 98,254 98,254 1
1 36 70300146 100 EA 100 per BOX Nairet Tablet 2.5 mg 2,318 231,800 1
1 37 700006305 1 BOX 250 per BOX Neurobion 5000 Tablet 627,801 627,801 1
1 38 700001532 12 BOT 12 per BOX Norit 125 mg Tablet 11,226 134,712 1
1 39 70301048 5 AM 5 per - Novalgin 2 ml Ampoule 10,788 53,940 1
2 40 70300044 24 EA 12 per BOX OBH Special 55 ml Syrup 17,964 431,136 2
3 41 70301051 300 TB 100 per BOX Panadol Cold And Flu (Green) Caplet 819 245,700 3
6 42 70301020 6 BOT - BOX Plantacid 100 ml Suspension 9,841 59,046 6
1 43 70301002 6 AM 6 per BOX Primperan Injection (Ampoule) 9,477 56,862 1
2 44 700006302 2 BOX 50 per - Rhinos SR Capsule 239,355 478,710 2
1 45 700001633 1 BOX 5 per BOX Sandostatin 0.1 mg/ml Ampoule 1,551,654 1,551,654 1
1 46 70301022 100 TB 100 per BOX Sanmag Tablet 745 74,500 1
1 47 70300019 36 EA 36 per BOX Silk Atr.Needle W 321 2/0 53,103 1,911,708 1
2 48 70300182 40 EA 20 per - Sinova 10 mg Tablet 1,133 45,320 2
1 49 70301011 60 TB 60 per - Tenace 5 mg Tablet 2,942 176,520 1
6 50 70300056 6 EA - BOX Thrombophob 20 g Gel 51,195 307,170 6
Total : 15,787,319.00

Diajukan oleh: Disetujui oleh: Catatan:

Nama :: dr. Wahyu Satria Nama : Candra Gupta M Parapat

ID : 2002-9889 ID : 085282
Tgl. : 8-Maret-2019 Tgl. : 8-Maret-2019