Dokter 5

RS SANTA ELISABETH SEI LEKOP
Kav. Sungai Lekop Kel. Sungai Lekop

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685
Laporan Penjualan Resep Rawat Darurat Per Dokter

Periode : 01-February-2022 s/d 28-February-2022
Jenis resep : Rawat Darurat

No. No. Resep Tgl. Resep No. Reg No. Bukti Nama Pasien Jumla
R/ Nama Item Qty Satuan Harga Jumlah Generik Non Gene

Formula Non Formula
Dokter : DR. ANDI EKA PUTRA
1 RD20220203-0001 03/02/2022 EP20220203-0001 2022020300001 MUHAMMAD AVATAR 17,600.0
R/ PAMOL 125 MG SUPP 1.00 SUPP 17,600.00 17,600.00 0 1
2 RD20220203-0002 03/02/2022 EP20220203-0001 2022020300002 MUHAMMAD AVATAR 295,888.0
R/ RHINOS JUNIOR SYR (PREK) 1.00 BTL 52,800.00 52,800.00 0 0
R/ SANMOL 60 ML SYR 1.00 FLS 16,088.00 16,088.00 0 1
R/ ISPRINOL 60 ML SYR 1.00 FLS 110,000.00 110,000.00 0 1
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1
3 RD20220203-0003 03/02/2022 EP20220203-0002 2022020300003 KEVIN ANJASWANA SILABAN 143,945.0
R/ LAPRAZ 30 MG CAP 5.00 CAP 16,473.00 82,365.00 0 1
R/ SANMOL 500 MG TABLET 10.00 TAB 408.00 4,080.00 0 1
R/ PROZA KAPLET 5.00 KAPLET 11,500.00 57,500.00 0 1
4 RD20220216-0034 16/02/2022 EP20220216-0033 2022021600057 RUTH MONICA SIHOTANG 194,435.0
R/ PROPEPSA 100 ML SYR 1.00 FLS 83,070.00 83,070.00 0 1
R/ PROVITAL PLUS CAPS 5.00 CAP 5,800.00 29,000.00 0 1
5 RD20220216-0035 16/02/2022 EP20220216-0034 2022021600058 SABINA ARTINDIRANI PUTRI 70,400.0
R/ RHINOS NEO DROP (PREK) 1.00 FLS 70,400.00 70,400.00 0 0
6 RD20220217-0002 17/02/2022 EP20220217-0002 2022021700002 M.NUR ALIF ADI TRIANSYAH 8,165.0
R/ PARACETAMOL 500 MG 4.00 KAPLET 185.00 740.00 1 0

KAPLET
R/ AMBROXOL 30 MG TAB 5.00 TAB 285.00 1,425.00 1 0
R/ CETIRIZINE 10 MG TAB 5.00 TAB 1,000.00 5,000.00 1 0
R/ KERTAS PERKAMEN BERLOGO 10.00 LBR 1.00 100.00 1,000.00 0 1
7 RD20220217-0003 17/02/2022 EP20220217-0003 2022021700005 NOPASARI SILITONGA 183,110.0
R/ ACETYLCYSTEIN 200 MG 10.00 CAP 1,485.00 14,850.00 1 0

CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
R/ RHINOS SR KAPSUL 10.00 CAP 8,067.00 80,670.00 0 1

(PREKURSOR)
R/ VITAMIN C XON-CE KAPLET 10.00 KAPLET 1.00 10.00 0 1

8 RD20220217-0004 17/02/2022 EP20220217-0005 2022021700007 22,653.0
Print Date:7/14/2022 Print Time: 2:11:10PM Page 1 of 190

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DOMPERIDON 60 ML SYR 1.00 FLS 15,813.00 15,813.00 1 0
R/ PARACETAMOL SYR 60 ML 1.00 FLS 6,840.00 6,840.00 1 0
9 RD20220217-0005 17/02/2022 EP20220217-0006 2022021700010 IMAM NAWAWI 58,048.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
R/ RANITIDINE 150 MG TAB 10.00 TAB 200.00 2,000.00 1 0
R/ TREMENZA 60 ML SYR (PREK) 1.00 FLS 28,188.00 28,188.00 0 1
R/ PARACETAMOL 500 MG 10.00 KAPLET 185.00 1,850.00 1 0

KAPLET
10 RD20220217-0006 17/02/2022 EP20220217-0009 2022021700027 26,010.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
11 RD20220217-0007 17/02/2022 EP20220217-0007 2022021700019 JEFRI ROLLI RICHARDO 58,898.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

KAPLET
12 RD20220217-0030 17/02/2022 EP20220217-0007 2022021700065 JEFRI ROLLI RICHARDO 10,800.0
R/ ASERING 500 ML INF 1.00 FLS 10,800.00 10,800.00 0 1
Total Dokter DR. ANDI EKA PUTRA 1,089,952.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685
Laporan Penjualan Resep Rawat Jalan Per Dokter

Jenis resep : Rawat Jalan


Formula Non Formula
Dokter : DR. BERNARD PARDOMUAN PURBA, SPB
1 RJ20220202-0008 02/02/2022 OP20220202-0014 2022020200014 BREMA S.P TUMANGGOR 1,500.0
R/ VITAMIN B COMPLEX TAB 10.00 TAB 150.00 1,500.00 1 0
2 RJ20220202-0009 02/02/2022 OP20220202-0015 2022020200015 SUMAIRI 3,350.0

KAPLET
3 RJ20220204-0002 04/02/2022 OP20220204-0006 2022020400003 ERNI PURBA 1,500.0
Total Dokter DR. BERNARD PARDOMUAN PURBA, SPB 6,350.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DRG. BETTY PASARIBU
1 RJ20220202-0002 02/02/2022 OP20220202-0004 2022020200004 ARING LAILIL MUKHAROMAH 66,960.0
R/ SPUIT 3 CC (TERUMO) 1.00 PCS 4,600.00 4,600.00 1 0
R/ MEFINAL 500 MG KAPLET 10.00 KAPLET 1,836.00 18,360.00 0 1
R/ AMOXAN 500 MG CAPSUL 10.00 CAP 4,400.00 44,000.00 0 1
2 RJ20220202-0005 02/02/2022 OP20220202-0013 2022020200011 ASEP RAFQI SULAIMAN 18,360.0
3 RJ20220203-0005 03/02/2022 OP20220203-0007 2022020300007 DICKY LAKSAMANA 5,810.0
R/ ASAM MEFENAMAT 500 MG 10.00 KAPLET 239.00 2,390.00 1 0

KAPLET
R/ AMOXICILLIN 500 MG KAPLET 10.00 KAPLET 342.00 3,420.00 1 0
4 RJ20220203-0006 03/02/2022 OP20220203-0007 2022020300008 DICKY LAKSAMANA 3,892.0
R/ PEHACAIN INJEKSI 2 ML 1.00 AMP 3,892.00 3,892.00 0 1
5 RJ20220203-0007 03/02/2022 OP20220203-0009 2022020300009 ROINCAH TOGATOROP 91,804.0
R/ BECOM C KAPLET 10.00 KAPLET 2,166.00 21,660.00 0 1
6 RJ20220204-0003 04/02/2022 OP20220204-0007 2022020400004 DONDA WEDIA ASTUTI SILALA 71,392.0
R/ SPUIT 50 ML SONDE 1.00 PCS 67,500.00 67,500.00 0 1

(CATHETER TIP) TERUMO
7 RJ20220207-0005 07/02/2022 OP20220207-0011 2022020700008 RAME PASARIBU 20,190.0
8 RJ20220208-0001 08/02/2022 OP20220208-0003 2022020800003 KHAIRUL NIZAM 20,190.0
9 RJ20220208-0005 08/02/2022 OP20220208-0005 2022020800007 ARING LAILIL MUKHAROMAH 13,880.0
R/ SPUIT 1 CC TERUMO 1.00 PCS 9,280.00 9,280.00 0 1
10 RJ20220209-0006 09/02/2022 OP20220209-0012 2022020900008 SIPORA 66,390.0

R/ DEXAMETHASON 0,5 MG TAB 10.00 TAB 220.00 2,200.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
11 RJ20220210-0002 10/02/2022 OP20220210-0004 2022021000003 AE SRIUTAMI 18,644.0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0

KAPLET
12 RJ20220211-0004 11/02/2022 OP20220211-0006 2022021100004 DEDI HERWANTO 64,190.0
13 RJ20220216-0012 16/02/2022 OP20220216-0014 2022021600016 IBROHIM 42,360.0
R/ CLINDAMYCIN 300 MG CAP 10.00 CAP 1,818.00 18,180.00 1 0
R/ CORTIDEX 0,5 MG TAB 10.00 TAB 399.00 3,990.00 0 1
14 RJ20220216-0013 16/02/2022 OP20220216-0015 2022021600017 HIROSIMA SIHOMBING 13,880.0
R/ SPUIT 1 CC TERUMO 1.00 PCS 9,280.00 9,280.00 0 1
15 RJ20220221-0012 21/02/2022 OP20220221-0016 2022022100013 SARILAN HARAHAP 9,960.0
R/ IBUPROFEN 400 MG TAB 10.00 TAB 514.00 5,140.00 1 0
16 RJ20220222-0001 22/02/2022 OP20220222-0002 2022022200001 MALA FITRI YANTI 3,892.0
17 RJ20220222-0006 22/02/2022 OP20220222-0005 2022022200006 ZENI SILVIA 70,282.0
18 RJ20220222-0007 22/02/2022 OP20220222-0006 2022022200007 MULIA RAHMAD 64,190.0

19 RJ20220223-0006 23/02/2022 OP20220223-0006 2022022300007 WANDEDI 3,892.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Total Dokter DRG. BETTY PASARIBU 678,870.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685
Laporan Penjualan Resep Rawat Inap Per Dokter

Jenis resep : Rawat Inap


Formula Non Formula
Dokter : DR. IKHSAN, SP.B
1 RI20220202-0019 02/02/2022 RI20220202-0002 RI20220202-0019 SUMUANG EFENDI SIMAMORA 18,460.0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ KAPAS ALKOHOL 6.00 PCS 303.00 1,818.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
3 RI20220202-0027 02/02/2022 RI20220202-0002 RI20220202-0027 SUMUANG EFENDI SIMAMORA 27.0
R/ BICNAT TAB 3.00 TAB 9.00 27.00 1 0
R/ FUROSEMIDE 10 MG/2 ML INJ 1.00 AMP 4,960.00 4,960.00 1 0
R/ UNDER PAD 60 X 90 2.00 PCS 7,024.00 14,048.00 0 1
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ ANEMOLAT 1 MG TAB 1.00 TAB 200.00 200.00 0 1
R/ SPASMINAL TABLET 3.00 TAB 817.00 2,451.00 0 1
8 RI20220203-0003 03/02/2022 RI20220202-0004 RI20220203-0003 MULIAN 69,712.0
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ SURFLO NO. 20 VENFLON 1.00 PCS 22,680.00 22,680.00 1 0
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ SURFLO NO. 18 (VENFLON) 1.00 PCS 29,200.00 29,200.00 0 1
R/ KAPAS ALKOHOL 3.00 PCS 303.00 909.00 0 1
R/ SELANG O2 DEWASA 1.00 PCS 10,626.00 10,626.00 0 1
R/ SUNGKUP OKSIGEN DEWASA 1.00 PCS 24,300.00 24,300.00 0 1
R/ DEXAMETHASONE 5MG/1ML 1.00 AMP 3,003.00 3,003.00 1 0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ FOLEY CATHETER NO. 16 1.00 PCS 24,975.00 24,975.00 0 1
R/ MEROPENEM INJEKSI 1 GR 3.00 VIAL 96,250.00 288,750.00 1 0
11 RI20220203-0015 03/02/2022 RI20220202-0004 RI20220203-0015 MULIAN 47,758.0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
R/ ELEKTRODA 3M RED DOT 2239 5.00 PCS 1,430.00 7,150.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ AQUADEST 1000 ML 1.00 FLS 32,134.00 32,134.00 1 0
R/ SPUIT 50 ML (WITHOUT 1.00 PCS 37,206.00 37,206.00 0 1

NEEDLE) ONEMED
R/ NALD 18 (ONEMED) 1.00 PCS 861.00 861.00 1 0
R/ THREE WAY STOP CO-CKS 1.00 PCS 31,460.00 31,460.00 0 1
R/ EXTENSION TUBE 150 CM X 1.00 PCS 62,944.00 62,944.00 0 1

1,5 ML
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ KCL 7.46% 25 ML 1.00 FLS 11,686.00 11,686.00 0 1
R/ SUNGKUP NEBULEZER 1.00 PCS 72,800.00 72,800.00 0 1

DEWASA
CAPSUL
R/ PULMICORT 0.5 MG/ML NEB 1.00 FLS 7,890.00 7,890.00 0 1
(BPJS)
R/ SUNGKUP O2(NON- 1.00 PCS 44,000.00 44,000.00 1 0
REBREATHER OXYGEN MASK)
18 RI20220204-0004
DWS 04/02/2022 RI20220202-0002 RI20220204-0004 SUMUANG EFENDI SIMAMORA 352,515.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685


R/ Nama Item Qty Satuan Harga Jumlah Generik Non

Generik
Formula Non Formula
R/ AQUADES 25 ML 125.00 CC 356.00 44,500.00 0 1
R/ BISOPROLOL 5 MG TAB 1.00 TAB 3,134.00 3,134.00 1 0

CAPSUL
R/ LODIA 2 MG TABLET 2.00 TAB 1,375.00 2,750.00 0 1
19 RI20220204-0011 04/02/2022 RI20220202-0004 RI20220204-0011 MULIAN 46,000.0
R/ DEXKETOPROFEN 25 MG TAB 10.00 TAB 4,600.00 46,000.00 1 0
20 RI20220204-0014 04/02/2022 RI20220204-0001 RI20220204-0014 MUHAMAD ZAENAL ARIFIN 20,852.0
R/ NALD 26 (ONEMED) 2.00 PCS 660.00 1,320.00 0 0
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ RAMIPRIL 5 MG TAB (BPJS) 2.00 TAB 857.00 1,714.00 1 0
R/ ANEMOLAT 1 MG TAB 6.00 TAB 200.00 1,200.00 0 1
R/ NALD 18 (ONEMED) 1.00 PCS 861.00 861.00 1 0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ SPUIT 10 CC ( TERUMO ) 2.00 PCS 11,242.00 22,484.00 0 1
R/ OMEPRAZOLE 40 MG INJ 2.00 VIAL 63,360.00 126,720.00 1 0
R/ STARXON 1 GR INJ 2.00 VIAL 326,563.00 653,126.00 0 1
R/ TROLAC 30 MG/ML INJ 3.00 AMP 41,250.00 123,750.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
27 RI20220206-0014 06/02/2022 RI20220206-0003 RI20220206-0014 REZA HAQQI 80,107.0
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1

(BPJS)
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ ASAM TRANEKSAMAT INJ 3.00 AMP 8,085.00 24,255.00 1 0

500MG/5ML
30 RI20220207-0013 07/02/2022 RI20220207-0001 RI20220207-0013 MULIANTA SITEPU 204,132.0

500MG/5ML
(BPJS)
R/ ANADIUM KAPLET 2.00 KAPLET 11,172.00 22,344.00 0 1
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
31 RI20220207-0017 07/02/2022 RI20220207-0002 RI20220207-0017 FATMAWATI 473,004.0
R/ DEXTROSE 5% 500 ML INF 1.00 FLS 21,040.00 21,040.00 0 1
R/ NALD NOVORAPID 32G 1.00 PCS 5,075.00 5,075.00 0 0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

(BPJS)

500MG/5ML

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(BPJS)

(BPJS)

500MG/5ML
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1

(BPJS)
500MG/5ML

R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

(BPJS)
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

500MG/5ML

(BPJS)
45 RI20220209-0018 09/02/2022 RI20220207-0001 RI20220209-0018 MULIANTA SITEPU 555.0

KAPLET

(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

(BPJS)
R/ UNDER PAD 60 X 90 1.00 PCS 7,024.00 7,024.00 0 1
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ HANDSCOEN STERIL NO. 6.5 1.00 PSG 21,162.00 21,162.00 0 1
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
52 RI20220210-0019 10/02/2022 RI20220210-0001 RI20220210-0019 LISNA SITORUS 126,529.0
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ CUTICELL CLASSIC 10 CM X 10 2.00 PCS 16,740.00 33,480.00 0 1

CM
R/ SAGESTAM 40 MG INJ 4.00 AMP 19,993.00 79,972.00 0 1
R/ UNDER PAD 60 X 90 1.00 PCS 7,024.00 7,024.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

(BPJS)
57 RI20220210-0031 10/02/2022 RI20220207-0002 RI20220210-0031 FATMAWATI 555.0

KAPLET
R/ LEVEMIR FLEXPEN (BPJS) 1.00 VIAL 80,909.00 80,909.00 0 1

(BPJS)
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ ARDIUM 500 MG 2.00 TAB 7,700.00 15,400.00 0 1
61 RI20220210-0041 10/02/2022 RI20220210-0002 RI20220210-0041 RIYANDRE PRATAMA 86,604.0
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

(BPJS)
R/ KASA GULUNG KECIL 15 CM 2.00 ROLL 5,168.00 10,336.00 0 1
65 RI20220211-0012 11/02/2022 RI20220210-0002 RI20220211-0012 RIYANDRE PRATAMA 136,486.0
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1

(BPJS)
66 RI20220211-0016 11/02/2022 RI20220211-0002 RI20220211-0016 ARTOTONG 10,626.0
67 RI20220211-0020 11/02/2022 RI20220211-0002 RI20220211-0020 ARTOTONG 7,150.0

KAPLET
69 RI20220211-0028 11/02/2022 RI20220211-0002 RI20220211-0028 ARTOTONG 44,000.0

70 RI20220211-0030
DWS 11/02/2022 RI20220211-0002 RI20220211-0030 ARTOTONG 69,500.0
R/ MANITOL 20 % 500 ML INF 1.00 FLS 69,500.00 69,500.00 0 1
71 RI20220211-0031 11/02/2022 RI20220211-0002 RI20220211-0031 ARTOTONG 16,006.0
R/ TRAMADOL 50MG/2ML INJ 2.00 AMP 8,003.00 16,006.00 1 0

(OOT)
72 RI20220211-0032 11/02/2022 RI20220211-0002 RI20220211-0032 ARTOTONG 39,999.0
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
73 RI20220212-0002 12/02/2022 RI20220211-0002 RI20220212-0002 ARTOTONG 309,280.0

R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ TONG SPATEL 2.00 PCS 644.00 1,288.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ CITICOLINE 250 MG/2ML 4.00 AMP 30,938.00 123,752.00 0 1

INJEKSI
(OOT)

(BPJS)
75 RI20220213-0008 13/02/2022 RI20220211-0002 RI20220213-0008 ARTOTONG 305,040.0

(BPJS)
INJEKSI

(OOT)
76 RI20220213-0010 13/02/2022 RI20220211-0002 RI20220213-0010 ARTOTONG ###
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
77 RI20220213-0018 13/02/2022 RI20220211-0002 RI20220213-0018 ARTOTONG 61,876.0

INJEKSI
78 RI20220214-0002 14/02/2022 RI20220211-0002 RI20220214-0002 ARTOTONG 61,876.0

INJEKSI
79 RI20220214-0006 14/02/2022 RI20220211-0002 RI20220214-0006 ARTOTONG 10,626.0
80 RI20220214-0021 14/02/2022 RI20220211-0002 RI20220214-0021 ARTOTONG 187,143.0

INJEKSI
81 RI20220214-0035 14/02/2022 RI20220211-0002 RI20220214-0035 ARTOTONG 39,999.0
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
82 RI20220214-0038 14/02/2022 RI20220211-0002 RI20220214-0038 ARTOTONG 861.0
R/ NALD 18 (ONEMED) 1.00 PCS 861.00 861.00 1 0
83 RI20220215-0009 15/02/2022 RI20220211-0002 RI20220215-0009 ARTOTONG 137,505.0
R/ CITICOLINE 500 MG TAB 15.00 TAB 9,167.00 137,505.00 0 1

84 RI20220215-0019 15/02/2022 RI20220215-0002 RI20220215-0019 JEPRI PARULIAN SIHOMBING 110,799.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1

500MG/5ML
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
87 RI20220216-0023 16/02/2022 RI20220216-0003 RI20220216-0023 GUSTAM RIKYANTO 165,872.0

INJEKSI
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
88 RI20220216-0024 16/02/2022 RI20220216-0003 RI20220216-0024 GUSTAM RIKYANTO 660.0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

INJEKSI
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

INJEKSI

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
93 RI20220218-0027 18/02/2022 RI20220218-0002 RI20220218-0027 PUSPA DEWI 25,771.0
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

KAPLET
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0
R/ UNDER PAD 60 X 90 3.00 PCS 7,024.00 21,072.00 0 1

(BPJS)

(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

KAPLET
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ TRANSOFIX 1.00 PCS 19,600.00 19,600.00 0 1
99 RI20220221-0033 21/02/2022 RI20220221-0001 RI20220221-0033 NODES SETIYAWAN 40,827.0
R/ NALD 26 (ONEMED) 3.00 PCS 660.00 1,980.00 0 0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ NALD 23 (ONEMED) 1.00 PCS 1,813.00 1,813.00 0 1

101 RI20220221-0046 21/02/2022 RI20220221-0003 RI20220221-0046 MIKO TSABET 76,232.0
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1

(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ NALD 26 (TERUMO) 1.00 PCS 4,713.00 4,713.00 0 1
107 RI20220223-0007 23/02/2022 RI20220221-0001 RI20220223-0007 NODES SETIYAWAN 388.0

KAPLET
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

(BPJS)
(BPJS)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

500MG/5ML
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

(BPJS)
111 RI20220224-0020 24/02/2022 RI20220224-0001 RI20220224-0020 MULIANTA SITEPU 1,129,492.0
R/ FAVIPIRAVIR 200 MG TABLET 16.00 TAB 24,300.00 388,800.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0
R/ RESFAR 25 ML 2.00 FLS 280,192.00 560,384.00 0 1
R/ ZEMINDO 60 ML SYR 2.00 BTL 52,800.00 105,600.00 0 1

CAPSUL

CAPSUL
R/ HANDSCOEN STERILE 1.00 PSG 18,900.00 18,900.00 0 1

(GAMMEX) NO. 7
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

500MG/5ML
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

500MG/5ML
CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

500MG/5ML

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

(GAMMEX) NO. 7
R/ FAVIKAL 200 MG TABLET 6.00 TAB 21,120.00 126,720.00 0 1

CAPSUL

(BPJS)

CAPSUL
118 RI20220227-0009 27/02/2022 RI20220224-0001 RI20220227-0009 MULIANTA SITEPU 1,001,141.0
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 6.00 TAB 2,600.00 15,600.00 0 1

500MG/5ML
CAPSUL
R/ NACL 0.9 % 500 ML INF 5.00 FLS 13,333.00 66,665.00 1 0

(BPJS)
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

500MG/5ML

CAPSUL
R/ DEVIT 1000 IU 5.00 TAB 2,600.00 13,000.00 0 1
124 RJ20220202-0001 02/02/2022 OP20220202-0002 2022020200002 HARIANTI 2,250.0
125 RJ20220202-0004 02/02/2022 OP20220202-0008 2022020200007 SUMUANG EFENDI SIMAMORA 39,999.0
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
126 RJ20220202-0007 02/02/2022 OP20220202-0008 2022020200013 SUMUANG EFENDI SIMAMORA 60,552.0
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
127 RJ20220203-0001 03/02/2022 OP20220203-0002 2022020300002 ULAN PRAWATI 69,000.0
128 RJ20220203-0003 03/02/2022 OP20220203-0006 2022020300005 MUHAMAD ZAENAL ARIFIN 69,000.0
129 RJ20220204-0001 04/02/2022 OP20220204-0001 2022020400001 DAMIANUS BEWAT 69,000.0
130 RJ20220207-0006 07/02/2022 OP20220207-0007 2022020700009 ROHANA BUTAR- BUTAR 139,805.0
R/ DEXKETO 15.00 TAB 4,600.00 69,000.00 1 0

PROFEN
R/ CEFIXIME
25 MG 200 MG CAP 10.00 CAP 6,188.00 61,880.00 1 0
TAB
R/ METHYLPREDNISOLONE 4 MG 15.00 TAB 595.00 8,925.00 1 0
TAB
131 RJ20220207-0010 07/02/2022 OP20220207-0016 2022020700015 PANAHATTAN NAPITUPULU 87,000.0
R/ MECOBALAMIN 500 MCG TAB 15.00 TAB 1,200.00 18,000.00 1 0

R/ LEVOFLOXACIN 500 MG TAB 10.00 TAB 1,557.00 15,570.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
133 RJ20220210-0001 10/02/2022 OP20220210-0001 2022021000002 LISNA SITORUS 118,973.0
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
134 RJ20220211-0003 11/02/2022 OP20220211-0005 2022021100003 ARTOTONG 319,645.0
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0

(BPJS)
(OOT)
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ NALD 26 (ONEMED) 2.00 PCS 660.00 1,320.00 0 0

INJEKSI
135 RJ20220212-0002 12/02/2022 OP20220212-0006 2022021200004 GITHA PAKPAHAN 8,925.0

TAB
136 RJ20220214-0006 14/02/2022 OP20220214-0008 2022021400006 REZA HAQQI 1,850.0

KAPLET
137 RJ20220214-0008 14/02/2022 OP20220214-0009 2022021400009 FATMAWATI 2,775.0

KAPLET
138 RJ20220215-0003 15/02/2022 OP20220215-0005 2022021500003 LISNA SITORUS 4,576.0
R/ GENTALEX 5 MG CREAM 1.00 TUBE 4,576.00 4,576.00 0 1
139 RJ20220216-0010 16/02/2022 OP20220216-0012 2022021600011 FAHRI ALDIANO 1,850.0

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
141 RJ20220218-0005 18/02/2022 OP20220218-0009 2022021800006 RIYANDRE PRATAMA 69,000.0
R/ STAR AG GEL 50 GR 1.00 TUBE 210,000.00 210,000.00 0 1
143 RJ20220219-0002 19/02/2022 OP20220219-0003 2022021900003 ARTOTONG 137,505.0
144 RJ20220221-0002 21/02/2022 OP20220221-0001 2022022100002 GUSTAM RIKYANTO 5,820.0

KAPLET
145 RJ20220221-0004 21/02/2022 OP20220221-0005 2022022100004 MULIANTA SITEPU 69,000.0
148 RJ20220223-0003 23/02/2022 OP20220223-0002 2022022300004 EKSA MERIYATI PURBA 204,443.0
R/ BURNAZIN 35 GR CREAM 1.00 TUBE 73,563.00 73,563.00 0 1
R/ CEFIXIME 200 MG CAP 10.00 CAP 6,188.00 61,880.00 1 0
150 RJ20220226-0001 26/02/2022 OP20220226-0001 2022022600001 NODES SETIYAWAN 5,825.0

KAPLET
Total Dokter DR. IKHSAN, SP.B 17,244,341.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. DIKA CAHAYA PUTRI
1 RD20220214-0001 14/02/2022 EP20220214-0001 2022021400001 NOVIA RAMADHANI 92,520.0
R/ SANADRYL DMP 120 ML SYR 1.00 BTL 26,950.00 26,950.00 0 1

(OOT)
2 RD20220214-0002 14/02/2022 EP20220214-0003 2022021400007 DESI ERNAWATI 119,300.0
R/ VOMETA FT 10 MG TAB 10.00 TAB 5,867.00 58,670.00 0 1
R/ SANMOL FORTE TAB 10.00 TAB 468.00 4,680.00 0 1

(OOT)
3 RD20220214-0003 14/02/2022 EP20220214-0004 2022021400009 NURUL APRILIA 206,470.0
R/ KETOPROFEN 100 MG TAB 10.00 TAB 1,826.00 18,260.00 1 0
R/ ZOLLOCID CAPS 10.00 CAP 12,672.00 126,720.00 0 1
4 RD20220214-0004 14/02/2022 EP20220214-0002 2022021400010 RIKI RICARDO YUNUS 245,800.0
5 RD20220214-0005 14/02/2022 EP20220214-0005 2022021400011 MANGIRING GULTOM 204,410.0
6 RD20220214-0006 14/02/2022 EP20220214-0007 2022021400013 JUMALI WIDODO 253,000.0
R/ OSTEOR C 60 GR CREAM 1.00 TUBE 173,250.00 173,250.00 0 1
7 RD20220214-0007 14/02/2022 EP20220214-0009 2022021400015 HASTONI 41,468.0

R/ CENDO XITROL 5 ML EYE 1.00 DROP 36,788.00 36,788.00 0 0

DROP

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
8 RD20220214-0008 14/02/2022 EP20220214-0010 2022021400016 SAHAT PARULIAN SIREGAR 249,435.0
R/ CORMEGA SOFT CAPS 10.00 CAP 13,200.00 132,000.00 0 1
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
R/ VOMIZOLE 20 MG TAB 5.00 TAB 19,433.00 97,165.00 0 1
R/ ORALIT SACHET 10.00 SACH 515.00 5,150.00 0 1
9 RD20220214-0010 14/02/2022 EP20220214-0013 2022021400023 LALU MUH SATRIA BUDI 1,850.0

PRATAMA

KAPLET
10 RD20220214-0011 14/02/2022 EP20220214-0012 2022021400027 NANDA ADITIA PRIMA DEWI 26,950.0
ARIFIN

(OOT)
11 RD20220214-0012 14/02/2022 EP20220214-0012 2022021400028 NANDA ADITIA PRIMA DEWI 239,382.0
ARIFIN
R/ FREGO 5 MG TAB 10.00 TAB 8,448.00 84,480.00 0 0
R/ MERTIGO 6 MG TAB 10.00 TAB 4,987.00 49,870.00 0 1
12 RD20220214-0013 14/02/2022 EP20220214-0006 2022021400029 RAHMA YUNIARTI ALI 132,528.0
R/ CERINI 10 MG TABLET 10.00 TAB 4,716.00 47,160.00 0 1
R/ EPEXOL SYRUP 1.00 BTL 23,788.00 23,788.00 0 1
13 RD20220214-0014 14/02/2022 EP20220214-0011 2022021400030 OBE HERDIANTO SIMBOLON 125,200.0

(OOT)
R/ COLERGIS TABLET 10.00 TAB 3,667.00 36,670.00 0 1
14 RD20220214-0015 14/02/2022 EP20220214-0015 2022021400031 HALIMAH FITRI BATAMI 152,190.0
15 RD20220214-0016 14/02/2022 EP20220214-0016 2022021400032 RAHEL HELSI KAROLA 93,538.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
16 RD20220214-0017 14/02/2022 EP20220214-0018 2022021400033 CHRISTIN MEGAWATY 142,250.0

SIREGAR

(PREKURSOR)
17 RD20220214-0019 14/02/2022 EP20220214-0020 2022021400035 WIKY ALEX SANDRA 228,990.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
18 RD20220214-0020 14/02/2022 EP20220214-0019 2022021400036 NUR ANDINI SYAFITRI 20,190.0
19 RD20220214-0023 14/02/2022 EP20220214-0021 2022021400045 RANA AFRILIA PUTRI 339,285.0
R/ FREGO 5 MG TAB 2.00 TAB 8,448.00 16,896.00 0 0
R/ SANADRYL EXP 120 ML SYR 1.00 BTL 20,134.00 20,134.00 0 1

(PREKURSOR)
20 RD20220215-0025 15/02/2022 EP20220215-0022 2022021500027 PUTRI AYU SIHITE 242,870.0
21 RD20220215-0026 15/02/2022 EP20220215-0023 2022021500028 TOMMY WIJAYA MANURUNG 197,768.0
22 RD20220215-0027 15/02/2022 EP20220215-0024 2022021500030 DAME SIHOTANG 63,360.0

(BPJS)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
23 RD20220215-0028 15/02/2022 EP20220215-0024 2022021500031 DAME SIHOTANG 1,850.0

KAPLET
24 RD20220215-0029 15/02/2022 EP20220215-0025 2022021500032 RONALDO FEBRYAN 190,740.0

(OOT)
25 RD20220215-0030 15/02/2022 EP20220215-0026 2022021500033 TRI SARA NAINGGOLAN 63,360.0

(BPJS)
26 RD20220215-0031 15/02/2022 EP20220215-0026 2022021500034 TRI SARA NAINGGOLAN 61,900.0

KAPLET
R/ SUCRALFATE SYR 100 ML 1.00 FLS 57,200.00 57,200.00 1 0
27 RD20220215-0032 15/02/2022 EP20220215-0028 2022021500035 KINTAN HANNAN ASRAWI 159,800.0

DARMA
28 RD20220215-0033 15/02/2022 EP20220215-0027 2022021500038 ANDI SAPUTRA 64,020.0

(OOT)
29 RD20220215-0034 15/02/2022 EP20220215-0029 2022021500039 FUTRI SIHOMBING 190,740.0

(OOT)
30 RD20220215-0035 15/02/2022 EP20220215-0031 2022021500043 AGAM ABDILAH HASIBUAN 17,600.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
31 RD20220215-0036 15/02/2022 EP20220215-0031 2022021500044 AGAM ABDILAH HASIBUAN 15,813.0
KERTAS PERKAMEN BERLOGO 10.00 LBR 100.00 0.00 0 1
32 RD20220 15/02/2022 EP20220215-0030 2022021500045 RYAN RAMADHANI 138,938.0

215-0037
R/ CIPROFLOXACINE 500 MG TAB 10.00 TAB 591.00 5,910.00 1 0
33 RD20220215-0038 15/02/2022 EP20220215-0033 2022021500047 KHANZA ABIR ADZKIYA 66,000.0
R/ VOMETA SYR 60 ML 1.00 FLS 66,000.00 66,000.00 0 1
34 RD20220215-0039 15/02/2022 EP20220215-0034 2022021500048 JOVIAN ALEXSANDER 82,088.0
35 RD20220215-0041 15/02/2022 EP20220215-0035 2022021500056 NELLY RYANTY PAKPAHAN 7,940.0
R/ METOCLOPRAMIDE 10 MG TAB 10.00 TAB 186.00 1,860.00 1 0
36 RD20220215-0042 15/02/2022 EP20220215-0036 2022021500057 ZEFRI SIMANJUNTAK 224,910.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
37 RD20220215-0043 15/02/2022 EP20220215-0037 2022021500058 AMIRA RIZKI PUTRI 58,438.0
R/ PARACETAMOL INFUS 1.00 FLS 58,438.00 58,438.00 1 0

1GR/100 ML
38 RD20220215-0044 15/02/2022 EP20220215-0040 2022021500059 DINA MUSTIKA ROHMAH 69,760.0
R/ OMEPRAZOLE 20 MG CAP 10.00 CAP 742.00 7,420.00 1 0
39 RD20220215-0045 15/02/2022 EP20220215-0040 2022021500060 DINA MUSTIKA ROHMAH 136,360.0

R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
40 RD20220215-0046 15/02/2022 EP20220215-0042 2022021500063 M.RIZKI NANDA 27,180.0
41 RD20220215-0047 15/02/2022 EP20220215-0038 2022021500065 SHEIVIA AQHILLA 95,838.0

MAHDALENA

(OOT)
42 RD20220215-0048 15/02/2022 EP20220215-0039 2022021500064 IRMA SITEPU 211,449.0

(PREKURSOR)
R/ FLUNARIZINE 5 MG TAB 5.00 TAB 1,760.00 8,800.00 1 0
43 RD20220215-0049 15/02/2022 EP20220215-0042 2022021500066 M.RIZKI NANDA 63,360.0
44 RD20220216-0021 16/02/2022 EP20220216-0021 2022021600036 AHMAD RIADI LUBIS 95,300.0
R/ INBUMIN TAB 250 MG 5.00 TAB 8,556.00 42,780.00 0 1
45 RD20220216-0022 16/02/2022 EP20220216-0020 2022021600037 OGENDO NAIBAHO 73,430.0
R/ NEW DIATAB TABLET 10.00 TAB 696.00 6,960.00 0 1

KAPLET
46 RD20220216-0023 16/02/2022 EP20220216-0022 2022021600038 NUR OKTAPIANI 39,670.0
47 RD20220216-0024 16/02/2022 EP20220216-0023 2022021600039 RIZKO HENDRAWAN 14,050.0

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
48 RD20220216-0025 16/02/2022 EP20220216-0025 2022021600042 DIANA SUMIATI 188,900.0
49 RD20220216-0026 16/02/2022 EP20220216-0024 2022021600043 GUSTAM RIKYANTO 105,876.0

INJEKSI
50 RD20220216-0027
DWS 16/02/2022 EP20220216-0026 2022021600047 CHRISTINA RONAULI SIAGIAN 150,020.0

(OOT)
51 RD20220216-0028 16/02/2022 EP20220216-0027 2022021600048 MIFTA WAHYU PUTRI 63,360.0

(BPJS)
52 RD20220216-0029 16/02/2022 EP20220216-0029 2022021600050 MARIA MAGDALENA HENUKH 31,000.0

KAPLET

(OOT)
53 RD20220216-0030 16/02/2022 EP20220216-0031 2022021600051 SUPRIYANTI 77,690.0
54 RD20220216-0031 16/02/2022 EP20220216-0030 2022021600052 SAUT P PANGARIBUAN 361,250.0
R/ LANFIX 100 MG KAPSUL 10.00 TAB 29,568.00 295,680.00 0 1
55 RD20220216-0032 16/02/2022 EP20220216-0030 2022021600053 SAUT P PANGARIBUAN 10,000.0
R/ FARBION INJ 1.00 AMP 10,000.00 10,000.00 0 1

56 RD20220216-0033 16/02/2022 EP20220216-0032 2022021600056 MONIKA SARAS WATI T 206,470.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
57 RD20220218-0001 18/02/2022 EP20220218-0001 2022021800001 IDA LAIA 63,360.0

(BPJS)
58 RD20220218-0002 18/02/2022 EP20220218-0001 2022021800004 IDA LAIA 20,170.0
59 RD20220218-0003 18/02/2022 EP20220218-0002 2022021800003 MARTUA SIBURIAN 63,360.0
60 RD20220218-0004 18/02/2022 EP20220218-0002 2022021800005 MARTUA SIBURIAN 12,000.0
R/ SUPRAFENID SUPP 1.00 SUPP 12,000.00 12,000.00 0 1
61 RD20220218-0006 18/02/2022 EP20220218-0004 2022021800012 WESLEY ARMANDO NABABAN 0.0
62 RD20220218-0009 18/02/2022 EP20220218-0003 2022021800017 RANI LESTARI MANURUNG 388.0

KAPLET
63 RD20220220-0001 20/02/2022 EP20220220-0001 2022022000001 ZHANG KAILI 138,080.0
64 RD20220221-0001 21/02/2022 EP20220221-0001 2022022100003 RISKI WAHYUDI SIKUMBANG 75,528.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
65 RD20220223-0002 23/02/2022 EP20220223-0002 2022022300003 ADITIA 297,460.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
66 RD20220223-0003 23/02/2022 EP20220223-0004 2022022300004 TRI APRILLENY 253,870.0
R/ GLUTAFIT CAPSUL 5.00 CAP 8,000.00 40,000.00 1 0
67 RD20220223-0004 23/02/2022 EP20220223-0003 2022022300005 FIONA OKTAVIANI 107,700.0

(OOT)
68 RD20220223-0005 23/02/2022 EP20220223-0005 2022022300007 YUNI LUKITO KARYA 7,340.0

KAPLET
R/ GLIBENCLAMIDE 5 MG TAB 10.00 TAB 126.00 1,260.00 1 0
R/ KASA GULUNG KECIL 15 CM 1.00 ROLL 5,168.00 5,168.00 0 1
70 RD20220223-0007 23/02/2022 EP20220223-0007 2022022300009 TRESIA SITUMORANG 44,680.0
71 RD20220223-0008 23/02/2022 EP20220223-0006 2022022300010 YUYUN PARIDA YANTI 146,000.0
R/ VIVENA INJ 2.00 VIAL 73,000.00 146,000.00 0 1
72 RD20220223-0009 23/02/2022 EP20220223-0006 2022022300011 YUYUN PARIDA YANTI 114,690.0
R/ BENOSON G 10 GR CREAM 1.00 TUBE 82,500.00 82,500.00 0 1
73 RD20220223-0010 23/02/2022 EP20220223-0008 2022022300014 DEWI KRISTINA BR SINAGA 29,890.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

KAPLET
74 RD20220223-0011 23/02/2022 EP20220223-0009 2022022300017 LISPIDA ROSTIKA 112,198.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
75 RD20220223-0012 23/02/2022 EP20220223-0010 2022022300020 DEWI SARTIKA SITINJAK 281,020.0
R/ BECOM ZET TAB 10.00 TAB 2,888.00 28,880.00 0 0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
76 RD20220224-0012 24/02/2022 EP20220224-0010 2022022400025 GIBRAN GHANI ALKHALID 110,276.0
77 RD20220224-0013 24/02/2022 EP20220224-0011 2022022400027 PANUTURAN SAMOSIR 115,360.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

(OOT)
78 RD20220224-0014 24/02/2022 EP20220224-0012 2022022400029 DIKI PRATAMA PUTRA 36,910.0

KAPLET
79 RD20220224-0015 24/02/2022 EP20220224-0013 2022022400037 KHATERIN YOLA GRANTSLICE 11,990.0
SIHOTANG

KAPLET
80 RD20220224-0016 24/02/2022 EP20220224-0014 2022022400038 SHINDY VALENTINA BR 88,410.0

NAPITUPULU


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
81 RD20220224-0017 24/02/2022 EP20220224-0015 2022022400039 RAUZATUN NURAKFAL 88,410.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
82 RD20220224-0018 24/02/2022 EP20220224-0017 2022022400042 MARIA DASILVA PIRE 63,360.0
83 RD20220224-0019 24/02/2022 EP20220224-0016 2022022400043 M.ADI MULIA 42,740.0

KAPLET
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
84 RD20220224-0020 24/02/2022 EP20220224-0017 2022022400044 MARIA DASILVA PIRE ###
85 RD20220224-0021 24/02/2022 EP20220224-0018 2022022400045 RENTANIA SEFTARITA 6,640.0

PANJAITAN
86 RD20220224-0022 24/02/2022 EP20220224-0019 2022022400046 MAHAMPUKATON GALANG 9,330.0

HAKIK
R/ DOMPERIDON 10 MG TAB 10.00 TAB 545.00 5,450.00 1 0

KAPLET
87 RD20220224-0023 24/02/2022 EP20220224-0019 2022022400047 MAHAMPUKATON GALANG 63,360.0
HAKIK

(BPJS)
88 RD20220224-0024 24/02/2022 EP20220224-0020 2022022400049 RIA RINDI SARI 63,360.0

(BPJS)
89 RD20220225-0021 25/02/2022 EP20220225-0025 2022022500044 HERMANSYAH 3,880.0
KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
90 RD20220226-0001 26/02/2022 EP20220226-0001 2022022600001 ABID RAFFASYAH PRANAJA 17,600.0
91 RD20220226-0003 26/02/2022 EP20220226-0002 2022022600004 TIOLINAR SIRUMAPEA 68,680.0

CAPSUL
R/ DEVIT 1000 IU 20.00 TAB 2,600.00 52,000.00 0 1
92 RD20220227-0010 27/02/2022 EP20220227-0004 2022022700012 ANGGUN MARAWULENG 131,208.0
R/ TREMENZA TABLET 10.00 TAB 2,001.00 20,010.00 0 1

(PREKURSOR)
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
93 RD20220227-0011 27/02/2022 EP20220227-0005 2022022700013 ENDAH DWI RIYANI 288,660.0
94 RD20220227-0012 27/02/2022 EP20220227-0006 2022022700014 DIAZ JOSHUA SIMAMORA 17,600.0
95 RD20220227-0013 27/02/2022 EP20220227-0006 2022022700015 DIAZ JOSHUA SIMAMORA 17,600.0
96 RD20220227-0015 27/02/2022 EP20220227-0006 2022022700017 DIAZ JOSHUA SIMAMORA 0.0
97 RD20220227-0016 27/02/2022 EP20220227-0007 2022022700018 RITA 13,990.0

KAPLET
Total Dokter DR. DIKA CAHAYA PUTRI 9,884,820.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. ERIE FAILENGGO
1 RD20220202-0003 02/02/2022 EP20220202-0003 2022020200003 ROZI KURNIA MARTA 521,318.0
R/ FREGO 5 MG TAB 5.00 TAB 8,448.00 42,240.00 0 0
R/ BETAHISTINE 6 MG TAB 10.00 TAB 881.00 8,810.00 1 0
R/ MELOXICAM 7,5 MG TAB 6.00 TAB 1,038.00 6,228.00 1 0
2 RD20220202-0005 02/02/2022 EP20220202-0006 2022020200008 PUTRI PRATIWI 251,085.0
R/ FREGO 5 MG TAB 5.00 TAB 8,448.00 42,240.00 0 0
3 RD20220202-0006 02/02/2022 EP20220202-0004 2022020200009 SITI MAIMUNAH RAMBE 313,634.0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
R/ AMLODIPINE 5 MG TAB 15.00 TAB 1,047.00 15,705.00 1 0
4 RD20220202-0007 02/02/2022 EP20220202-0007 2022020200010 ABDI SANTOSO 78,658.0
R/ FLAMAR EMULGEL 20 GR 1.00 TUBE 22,550.00 22,550.00 0 1

TAB
R/ BRAXIDIN TABLET 2.00 TAB 14,094.00 28,188.00 0 0
(PSIKOTROPIKA)
5 RD20220202-0008 02/02/2022 EP20220202-0010 2022020200013 MUHAMMAD IKHSAN ADHETYA 73,000.0

NUGRAHA
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1

6 RD20220202-0009 02/02/2022 EP20220202-0010 2022020200014 MUHAMMAD IKHSAN ADHETYA 191,290.0
NUGRAHA

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(PREKURSOR)
7 RD20220202-0010 02/02/2022 EP20220202-0009 2022020200015 LISA 448,924.0
8 RD20220202-0011 02/02/2022 EP20220202-0011 2022020200016 NERLY SIHOMBING 10,956.0
9 RD20220202-0012 02/02/2022 EP20220202-0013 2022020200017 YUNI MANULLANG 114,735.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
10 RD20220205-0005 05/02/2022 EP20220205-0005 2022020500009 ALMA FAUZIAH 72,270.0
R/ ANTASIDA DOEN SYR 1.00 FLS 7,800.00 7,800.00 1 0

KAPLET
(BPJS)
11 RD20220205-0006 05/02/2022 EP20220205-0006 2022020500010 ROIDA SIHOTANG 8,910.0

KAPLET
12 RD20220209-0004 09/02/2022 EP20220209-0002 2022020900004 OLIDI 85,016.0
R/ LANSOPRAZOLE 30 MG CAPS 6.00 CAP 1,689.00 10,134.00 1 0
R/ ONDANSETRON 4 MG TAB 6.00 TAB 2,167.00 13,002.00 1 0
13 RD20220209-0006 09/02/2022 EP20220209-0004 2022020900011 RAYA SIHOMBING 63,360.0

(BPJS)
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
14 RD20220209-0007 09/02/2022 EP20220209-0005 2022020900012 N.SAUT PARHITEAN 122,470.0

PAKPAHAN

KAPLET
15 RD20220209-0008 09/02/2022 EP20220209-0006 2022020900013 SARI KRISTIANI JULIETA BR 268,929.0

SIANTURI
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
16 RD20220209-0009 09/02/2022 EP20220209-0007 2022020900014 SIAME MANAO 10,080.0
17 RD20220209-0010 09/02/2022 EP20220209-0009 2022020900017 DIMAS ALDI PRATAMA 326,563.0
18 RD20220209-0011 09/02/2022 EP20220209-0009 2022020900018 DIMAS ALDI PRATAMA 7,813.0

KAPLET
19 RD20220209-0013 09/02/2022 EP20220209-0003 2022020900023 CLARA OLIVIA SINAGA 50,625.0
R/ ARMSLING SIZE M 1.00 PCS 50,625.00 50,625.00 0 1
20 RD20220210-0002 10/02/2022 EP20220210-0002 2022021000003 NADIA ZAHRA AMRI 179,872.0
21 RD20220210-0003 10/02/2022 EP20220210-0006 2022021000006 WISNU SYAHFITRI 200,218.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
22 RD20220210-0004 10/02/2022 EP20220210-0007 2022021000007 NANDA SURYA KUSUMA 160,038.0

(OOT)
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1
23 RD20220210-0005 10/02/2022 EP20220210-0005 2022021000008 ENDAH DWI RIYANI 60,630.0

(OOT)
24 RD20220210-0006 10/02/2022 EP20220210-0008 2022021000011 MUTIA ANGRAINI 67,180.0
25 RD20220210-0007 10/02/2022 EP20220210-0009 2022021000012 CHELSEA DWI NOVITA SARI 8,900.0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
26 RD20220210-0008 10/02/2022 EP20220210-0009 2022021000013 CHELSEA DWI NOVITA SARI 190,070.0
27 RD20220210-0009 10/02/2022 EP20220210-0010 2022021000015 PUTRI EISYA L SIMANJUNTAK 238,780.0
28 RD20220210-0010 10/02/2022 EP20220210-0013 2022021000019 PUTRI KIRANTI 8,900.0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
29 RD20220210-0011 10/02/2022 EP20220210-0011 2022021000020 RAFI YANDO RAMDAN 8,900.0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
30 RD20220210-0012 10/02/2022 EP20220210-0012 2022021000021 PUTRI APRILLIYANI 231,062.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
32 RD20220210-0014 10/02/2022 EP20220210-0011 2022021000023 RAFI YANDO RAMDAN 244,020.0

(OOT)
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
33 RD20220210-0016 10/02/2022 EP20220210-0016 2022021000025 PANGERAN HUTAGALUNG 17,600.0
34 RD20220210-0017 10/02/2022 EP20220210-0016 2022021000026 PANGERAN HUTAGALUNG 134,888.0
35 RD20220212-0001 12/02/2022 EP20220212-0002 2022021200001 NADA SUHALLAH 116,352.0

PAKPAHAN
37 RD20220212-0003 12/02/2022 EP20220212-0005 2022021200005 ERZON 377,240.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(OOT)
(PREKURSOR)
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
38 RD20220212-0004 12/02/2022 EP20220212-0004 2022021200006 MUHAMMAD HUSEIN 20,500.0

HERWANTO
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
39 RD20220213-0006 13/02/2022 EP20220213-0004 2022021300009 RISKA ROSSITA 494,734.0

(PREKURSOR)
40 RD20220213-0007 13/02/2022 EP20220213-0005 2022021300010 INDRI ULANDARI 73,000.0
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
41 RD20220213-0008 13/02/2022 EP20220213-0005 2022021300011 INDRI ULANDARI 284,890.0
R/ FREGO 5 MG TAB 5.00 TAB 8,448.00 42,240.00 0 0
42 RD20220213-0009 13/02/2022 EP20220213-0006 2022021300012 ANGGELINUS ARYANTO 83,732.0
43 RD20220213-0010 13/02/2022 EP20220213-0007 2022021300014 NURIA RITONGA 46,694.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
44 RD20220213-0011 13/02/2022 EP20220213-0008 2022021300019 MEYSTAVIA BERTA WAHYU 508,591.0

RENGGANIS
R/ FREGO 5 MG TAB 2.00 TAB 8,448.00 16,896.00 0 0

RENGGANIS
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
46 RD20220213-0013 13/02/2022 EP20220213-0010 2022021300021 SAHURI 36,910.0

KAPLET
47 RD20220213-0015 13/02/2022 EP20220213-0012 2022021300027 MARIA GISELA NONA 34,220.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
48 RD20220213-0019 13/02/2022 EP20220213-0013 2022021300039 SILVIA MAHESTI 10,626.0
49 RD20220214-0021 14/02/2022 EP20220214-0022 2022021400043 CHAIRUL AZMI 199,654.0

(PREKURSOR)
50 RD20220214-0022 14/02/2022 EP20220214-0023 2022021400044 NUR ASIYAH HASIBUAN 237,013.0
R/ FREGO 5 MG TAB 2.00 TAB 8,448.00 16,896.00 0 0
51 RD20220214-0024 14/02/2022 EP20220214-0024 2022021400046 SURUNG SIAHAAN 29,570.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
52 RD20220214-0025 14/02/2022 EP20220214-0025 2022021400047 MUHAMMAD ABIDZAR 44,773.0

ALGIFARI
R/ KERTAS PERKAMEN BERLOGO 9.00 LBR 1.00 100.00 900.00 0 1
53 RD20220214-0026 14/02/2022 EP20220214-0026 2022021400049 RUSMARIANA SITUMORANG 232,446.0

(PREKURSOR)
54 RD20220214-0027 14/02/2022 EP20220214-0027 2022021400050 NOVIATI 184,569.0

(PREKURSOR)
55 RD20220214-0028 14/02/2022 EP20220214-0028 2022021400053 HAMBALI MURDANI 619,360.0
56 RD20220214-0029 14/02/2022 EP20220214-0029 2022021400054 AGUS NOVITA 580,805.0
R/ FREGO 5 MG TAB 5.00 TAB 8,448.00 42,240.00 0 0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
57 RD20220214-0030 14/02/2022 EP20220214-0030 2022021400055 BOY HARPIT AKROMA 61,600.0
R/ REMOPAIN INJ AMPUL 1.00 AMP 61,600.00 61,600.00 0 1
58 RD20220214-0031 14/02/2022 EP20220214-0030 2022021400057 BOY HARPIT AKROMA 183,455.0
59 RD20220214-0032 14/02/2022 EP20220214-0031 2022021400058 CARINIH 172,500.0
60 RD20220214-0033 14/02/2022 EP20220214-0032 2022021400059 MAYA SANTI 127,910.0
R/ ALPRAZOLAM 0,5 MG TAB 3.00 TAB 790.00 2,370.00 0 0

(PSI)
61 RD20220214-0034 14/02/2022 EP20220214-0033 2022021400060 AURELIA TASHA TAMPUBOLON 80,670.0
R/ RANIVEL 75MG/5ML SYR 1.00 FLS 80,670.00 80,670.00 0 1
62 RD20220214-0035 14/02/2022 EP20220214-0034 2022021400061 CHRISTYANTO MANULLANG 135,190.0
63 RD20220215-0050 15/02/2022 EP20220215-0041 2022021500068 SRI UTAMI 114,700.0
64 RD20220215-0051 15/02/2022 EP20220215-0044 2022021500069 BENNY NABABAN 164,836.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ FREGO 5 MG TAB 2.00 TAB 8,448.00 16,896.00 0 0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
65 RD20220215-0052 15/02/2022 EP20220215-0043 2022021500074 DELFINORA PASARIBU 484,950.0

(PREKURSOR)
R/ CODEIN 10 MG TAB 10.00 TAB 925.00 9,250.00 0 0

(NARKOTIKA)
66 RD20220216-0001 16/02/2022 EP20220216-0001 2022021600002 SWARNADWIPA NOVANDIKA 508,010.0
PUTRA GIRSANG

(OOT)

(PREKURSOR)
67 RD20220218-0007 18/02/2022 EP20220218-0005 2022021800015 LINEKER EFRAIM NIXON 371,948.0

SILALAHI
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0

(PREKURSOR)
68 RD20220218-0008 18/02/2022 EP20220218-0006 2022021800016 ROIS IGREYA BARUS 218,450.0
R/ LANAKELOID 10 GR CREAM 1.00 TUBE 121,000.00 121,000.00 0 1

69 RD20220218-0010 18/02/2022 EP20220218-0007 2022021800018 LISTEN SIMANJUNTAK 143,000.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ PARAMOL 1GR/100 ML INF 1.00 FLS 70,000.00 70,000.00 0 1
70 RD20220218-0011 18/02/2022 EP20220218-0007 2022021800019 LISTEN SIMANJUNTAK 8,390.0
71 RD20220218-0012 18/02/2022 EP20220218-0008 2022021800021 NECI PURNAMA SARI 148,540.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
72 RD20220218-0013 18/02/2022 EP20220218-0011 2022021800027 SARWONO 127,189.0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
73 RD20220218-0014 18/02/2022 EP20220218-0010 2022021800028 KRISTINA ROMAULI SIAHAAN 522,024.0

(PREKURSOR)
74 RD20220218-0015 18/02/2022 EP20220218-0012 2022021800029 MUHAMMAD ILHAM SADIQ 73,000.0
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
75 RD20220218-0016 18/02/2022 EP20220218-0012 2022021800030 MUHAMMAD ILHAM SADIQ 184,689.0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
76 RD20220218-0017 18/02/2022 EP20220218-0009 2022021800034 PUSPA DEWI 68,750.0

R/ METRONIDAZOLE 1.00 FLS 68,750.00 68,750.00 1 0
500MG/100ML INFUS
77 RD20220218-0018 18/02/2022 EP20220218-0013 2022021800035 SESONIA KESYALIANI 117,280.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ AMBROXOL 15 MG/5ML SYR 1.00 FLS 12,375.00 12,375.00 1 0

TAB
R/ DEVIT 1000 IU 5.00 TAB 2,600.00 13,000.00 0 1
R/ RHINOS SR KAPSUL 10.00 CAP 8,067.00 ### 0 1

(PREKURSOR)
78 RD20220218-0019 18/02/2022 EP20220218-0014 2022021800040 PETRO BERLIN SIMANJUNTAK 107,760.0
R/ EPERISON 50 MG TAB 6.00 TAB 2,290.00 13,740.00 1 0
79 RD20220219-0004 19/02/2022 EP20220219-0006 2022021900011 SAFRIZAL 293,325.0
R/ TETAGAM INJEKSI (VAKSIN) 1.00 VIAL 293,325.00 293,325.00 0 1
80 RD20220219-0005 19/02/2022 EP20220219-0006 2022021900013 SAFRIZAL 140,230.0
81 RD20220219-0006 19/02/2022 EP20220219-0005 2022021900015 SHYALOMI LETHISIA KHEREN 20,500.0

MANURUNG
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
82 RD20220219-0007 19/02/2022 EP20220219-0007 2022021900016 RINDI ATIKA MARPAUNG 73,000.0
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
83 RD20220219-0008 19/02/2022 EP20220219-0007 2022021900017 RINDI ATIKA MARPAUNG 253,651.0

(PREKURSOR)

84 RD20220219-0009 19/02/2022 EP20220219-0008 2022021900018 BERLIANA SIREGAR 63,360.0

(BPJS)
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
85 RD20220219-0010 19/02/2022 EP20220219-0009 2022021900020 EDWARD RONANDO 2,448.0

TAMBUNAN
86 RD20220219-0011 19/02/2022 EP20220219-0011 2022021900023 MUTIARA IMANI GUSTI 285,979.0

(PREKURSOR)
87 RD20220219-0012 19/02/2022 EP20220219-0011 2022021900021 MUTIARA IMANI GUSTI 211,200.0
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
88 RD20220219-0013 19/02/2022 EP20220219-0012 2022021900024 RIANTO H MARPAUNG 211,200.0
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
89 RD20220219-0014 19/02/2022 EP20220219-0010 2022021900030 220,049.0

(PREKURSOR)
90 RD20220219-0015 19/02/2022 EP20220219-0010 2022021900027 DICKY ARDIANSYAH 211,200.0
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
91 RD20220219-0016 19/02/2022 EP20220219-0013 2022021900029 RISKA WAHYUNI 10,830.0
93 RD20220220-0011 20/02/2022 EP20220220-0011 2022022000030 TRY OCTAVANIA YANDRI 540,594.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(PREKURSOR)
94 RD20220220-0012 20/02/2022 EP20220220-0012 2022022000031 BINTA MINA BR SEMBIRING 191,700.0

(PREKURSOR)

(OOT)
95 RD20220220-0013 20/02/2022 EP20220220-0013 2022022000032 NURHALINA SIREGAR 282,575.0
96 RD20220220-0014 20/02/2022 EP20220220-0013 2022022000033 NURHALINA SIREGAR 61,600.0
97 RD20220220-0015 20/02/2022 EP20220220-0014 2022022000034 MUHAMMAD SYAFIQ AL FATIH 83,530.0
R/ COLERGIS 60 ML SYR 1.00 FLS 61,600.00 61,600.00 0 1
R/ SALICYL TALK 60 GR 1.00 POT 5,842.00 5,842.00 0 1
98 RD20220220-0016 20/02/2022 EP20220220-0015 2022022000035 WALID MARZUQI SARUMPAET 20,500.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
99 RD20220220-0017 20/02/2022 EP20220220-0016 2022022000038 LEO MARHASIAN 61,600.0
100 RD20220220-0018 20/02/2022 EP20220220-0016 2022022000039 LEO MARHASIAN 456,138.0
R/ METHYLON 4 MG TAB 6.00 TAB 3,163.00 18,978.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
101 RD20220220-0019 20/02/2022 EP20220220-0017 2022022000040 SRI WAHYUNI 61,600.0
102 RD20220220-0020 20/02/2022 EP20220220-0017 2022022000041 SRI WAHYUNI 539,254.0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
103 RD20220221-0033 21/02/2022 EP20220221-0031 2022022100076 BAKRI 217,800.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1

(OOT)
104 RD20220222-0001 22/02/2022 EP20220222-0001 2022022200003 IDHAM SYAFRIL 540,884.0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
105 RD20220224-0002 24/02/2022 EP20220224-0002 2022022400007 ANDRI HADI SURYA 356,685.0
R/ TETAGAM INJEKSI (VAKSIN) 1.00 VIAL 293,325.00 293,325.00 0 1
106 RD20220224-0003 24/02/2022 EP20220224-0003 2022022400008 INDAH MARTIANA PUTRI 272,585.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
108 RD20220224-0005 24/02/2022 EP20220224-0004 2022022400011 BOLONTUA MANURUNG 378,968.0
R/ EPEXOL TAB 10.00 TAB 1,141.00 11,410.00 0 1
109 RD20220224-0006 24/02/2022 EP20220224-0005 2022022400012 MULIANTA SITEPU 226,406.0
R/ SPONGOSTAN STANDART 1.00 PCS 226,406.00 226,406.00 0 1
110 RD20220224-0007 24/02/2022 EP20220224-0006 2022022400013 ZARA AFDHILLA SANDENA 326,319.0

PUTRI

(PSIKOTROPIKA)
R/ FREGO 5 MG TAB 6.00 TAB 8,448.00 50,688.00 0 0
111 RD20220224-0008 24/02/2022 EP20220224-0009 2022022400019 BUNYAMIN 259,550.0

(BPJS)
113 RD20220224-0010 24/02/2022 EP20220224-0007 2022022400023 4,685.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
114 RD20220224-0011 24/02/2022 EP20220224-0008 2022022400024 45,868.0
R/ DEVIT 1000 IU 5.00 TAB 2,600.00 13,000.00 0 1

PUTRI
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1

PUTRI

(PREKURSOR)
117 RD20220225-0018 25/02/2022 EP20220225-0022 2022022500040 ANI SARI SUSANTI 401,719.0
118 RD20220225-0019 25/02/2022 EP20220225-0023 2022022500041 DANI SAMUEL SINAGA 344,915.0
119 RD20220225-0020 25/02/2022 EP20220225-0024 2022022500042 WESLEY ARMANDO NABABAN 15,813.0
120 RD20220227-0004 27/02/2022 EP20220227-0001 2022022700004 LEO SIMANJUNTAK 22,146.0

121 RD20220227-0005 27/02/2022 EP20220227-0002 2022022700006 YANCE MAURICE MANURUNG 19,840.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
122 RD20220227-0006 27/02/2022 EP20220227-0002 2022022700007 169,903.0
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1

DEWASA
R/ ASPILET 80 MG TAB 1.00 TAB 729.00 729.00 0 0

(BPJS)
123 RD20220227-0007 27/02/2022 EP20220227-0002 2022022700008 YANCE MAURICE MANURUNG 62,944.0

1,5 ML
124 RD20220227-0008 27/02/2022 EP20220227-0003 2022022700010 ASHIFAN FAUZI SITORUS 302,308.0
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1

(OOT)
125 RD20220227-0009 27/02/2022 EP20220227-0003 2022022700011 ASHIFAN FAUZI SITORUS 35,200.0
126 RD20220228-0001 28/02/2022 EP20220228-0001 2022022800002 TERESIA AYULINA TIVANY 20,500.0

SIALLAGAN
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
Total Dokter DR. ERIE FAILENGGO 22,972,384.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. FERRY FHRANS VALENTINUS KARO-KARO
1 RD20220201-0007 01/02/2022 EP20220201-0005 2022020100011 ADE NOVIT SYAHPUTRA 292,600.0
2 RD20220201-0008 01/02/2022 EP20220201-0005 2022020100012 ADE NOVIT SYAHPUTRA 77,350.0
R/ TENSOCREPE 3 INC (7.5 CM X 1.00 ROLL 77,350.00 77,350.00 0 1

4.55 M)
3 RD20220202-0013 02/02/2022 EP20220202-0014 2022020200018 GIMSI HUTAGALUNG 267,790.0
4 RD20220202-0014 02/02/2022 EP20220202-0015 2022020200019 DICKY SERFINDO 215,590.0
5 RD20220202-0015 02/02/2022 EP20220202-0016 2022020200020 SUYETNO 421,335.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
6 RD20220202-0016 02/02/2022 EP20220202-0018 2022020200022 ARING LAILIL MUKHAROMAH 450,380.0
R/ BETAHISTINE 6 MG TAB 10.00 TAB 881.00 8,810.00 1 0
7 RD20220202-0017 02/02/2022 EP20220202-0020 2022020200023 CHINTA NADIRA PUTRI 72,934.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
8 RD20220202-0018 02/02/2022 EP20220202-0019 2022020200024 JONI 195,620.0
10 RD20220207-0017 07/02/2022 EP20220207-0015 2022020700023 RUDI YANTO 209,790.0
11 RD20220207-0018 07/02/2022 EP20220207-0016 2022020700024 ELKANA 275,924.0
12 RD20220207-0019 07/02/2022 EP20220207-0017 2022020700025 RUDI ARIYANTO 61,990.0
13 RD20220207-0020 07/02/2022 EP20220207-0018 2022020700026 FLOWERIDA SITANGGANG 267,790.0
14 RD20220207-0021 07/02/2022 EP20220207-0019 2022020700028 DANIEL CLYNTON SILAEN 371,900.0
R/ CALCIUM LACTATE 500 MG 10.00 TAB 303.00 3,030.00 1 0

TABLET
15 RD20220207-0022 07/02/2022 EP20220207-0020 2022020700029 RUDIANA 333,790.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
16 RD20220215-0011 15/02/2022 EP20220215-0011 2022021500013 DEWARNI PANGGABEAN 113,418.0
17 RD20220215-0012 15/02/2022 EP20220215-0012 2022021500015 NADIA PUTRI PALGA 108,300.0
R/ BETAMETASON 5 GR CREAM 1.00 TUBE 3,140.00 3,140.00 0 1
18 RD20220215-0013 15/02/2022 EP20220215-0013 2022021500014 SOHMA KUDADIRI 62,080.0
19 RD20220215-0014 15/02/2022 EP20220215-0014 2022021500016 AHMAD RIDHO AFRICANO 85,868.0
20 RD20220215-0015 15/02/2022 EP20220215-0015 2022021500017 MARLAN MANALU 98,800.0

CAPSUL
21 RD20220215-0016 15/02/2022 EP20220215-0017 2022021500018 ARYA DZAKI PERDANA 77,275.0
R/ EPEXOL DROPS 1.00 DROP 51,700.00 51,700.00 0 1
R/ SAN-B PLEX P DROP 1.00 FLS 25,575.00 25,575.00 0 1
22 RD20220215-0017 15/02/2022 EP20220215-0016 2022021500019 ESLINA SIMAMORA 70,000.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(PSIKOTROPIKA)
24 RD20220215-0019 15/02/2022 EP20220215-0017 2022021500021 ARYA DZAKI PERDANA 52,800.0
25 RD20220215-0020 15/02/2022 EP20220215-0018 2022021500022 ADISTY DIANE ROLIS 84,913.0
R/ SAGESTAM 10 GR CREAM 1.00 TUBE 16,913.00 16,913.00 0 1
26 RD20220215-0021 15/02/2022 EP20220215-0019 2022021500023 DENISSAH MUHARRAM 93,710.0
27 RD20220215-0023 15/02/2022 EP20220215-0020 2022021500051 168,822.0
R/ BUSCOPAN 20MG/ML INJ 1.00 AMP 48,262.00 48,262.00 0 1

(BPJS)
28 RD20220215-0024 15/02/2022 EP20220215-0021 2022021500026 MARIA BR SINAMBELA 104,480.0

CAPSUL
29 RD20220215-0040 15/02/2022 EP20220215-0020 2022021500053 HOKKOP SIMANJUNTAK 63,360.0

(BPJS)
Total Dokter DR. FERRY FHRANS VALENTINUS KARO- 5,193,225.0
KARO
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. FELIX VALERIAN HALIM
1 RD20220203-0004 03/02/2022 EP20220203-0003 2022020300004 NUR SYARIFAH 443,470.0

(PREKURSOR)
2 RD20220203-0005 03/02/2022 EP20220203-0004 2022020300005 WANTU HOTMAN SIHOMBING 37,540.0
3 RD20220203-0006 03/02/2022 EP20220203-0004 2022020300006 WANTU HOTMAN SIHOMBING 63,360.0

(BPJS)
4 RD20220203-0007 03/02/2022 EP20220203-0005 2022020300008 ANISA PUTRI 327,470.0
R/ ZINC SIRUP 20 MG/5ML 1.00 FLS 11,000.00 11,000.00 0 1
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
6 RD20220203-0009 03/02/2022 EP20220203-0008 2022020300010 SIMONE NATANEL NABABAN 105,678.0

CAPSUL
7 RD20220203-0010 03/02/2022 EP20220203-0009 2022020300011 RIVALDO ELDEST 18,360.0

HAMONANGAN PURBA
8 RD20220203-0011 03/02/2022 EP20220203-0010 2022020300012 SAMUEL KEVIN SIAHAAN 41,260.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
9 RD20220203-0012 03/02/2022 EP20220203-0011 2022020300013 NURHIKMAH SARI 307,380.0

MATONDANG
10 RD20220204-0001 04/02/2022 EP20220204-0001 2022020400001 SUDARNO 39,296.0

KAPLET
11 RD20220204-0002 04/02/2022 EP20220204-0003 2022020400003 NUWAIRA CARABELLA AZAHRA 96,939.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
12 RD20220204-0003 04/02/2022 EP20220204-0004 2022020400007 NATALIA NOPRIANTI BR 80,000.0

TARIGAN
13 RD20220207-0023 07/02/2022 EP20220207-0022 2022020700033 MUHAMMAD SIDIK 203,210.0
14 RD20220208-0002 08/02/2022 EP20220207-0021 2022020800002 NOVRIATI SIMANUNGKALIT 63,360.0

(BPJS)
15 RD20220208-0017 08/02/2022 EP20220208-0016 2022020800029 WYLIA DHARMA FITRI 392,240.0

(PREKURSOR)

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
16 RD20220208-0018 08/02/2022 EP20220208-0017 2022020800030 JIMMY SM NABABAN 6,600.0
R/ COTRIMOXAZOLE 480 MG 12.00 TAB 550.00 6,600.00 1 0

TABLET
17 RD20220209-0001 09/02/2022 EP20220209-0001 2022020900002 BERLIAN HUTAPEA 63,360.0

(BPJS)
18 RD20220209-0002 09/02/2022 EP20220209-0001 2022020900003 11,340.0
R/ VITAMIN B COMPLEX TAB 5.00 TAB 150.00 750.00 1 0
19 RD20220211-0003 11/02/2022 EP20220211-0003 2022021100007 KRISTIAN KERANS 89,516.0
R/ STESOLID 10 MG/2ML 1.00 AMP 16,108.00 16,108.00 0 0

INJEKSI (PSIKOTROPIKA)
R/ SELANG O2 ANAK 1.00 PCS 6,500.00 6,500.00 0 1
R/ STESOLID 5 MG/2.5 ML 2.00 TUBE 33,454.00 66,908.00 0 0

RECTAL TUBE
20 RD20220211-0004
(PSIKOTROPIKA) 11/02/2022 EP20220 2022021100008 YELVIDA 119,080.0
211-0004
21 RD20220211-0005 11/02/2022 EP20220211-0005 2022021100009 NURFITRI WITA NURFIQ 315,870.0
22 RD20220211-0006 11/02/2022 EP20220211-0004 2022021100011 YELVIDA 167,190.0
R/ FOLAMIL GENIO CAPSUL 30.00 TAB 5,573.00 167,190.00 0 1
23 RD20220211-0007 11/02/2022 EP20220211-0003 2022021100012 KRISTIAN KERANS 20,500.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
24 RD20220211-0008 11/02/2022 EP20220211-0006 2022021100015 EKA JERNITA LUMBAN 164,082.0

TORUAN
R/ EPEXOL TAB 10.00 TAB 1,141.00 11,410.00 0 1
25 RD20220211-0009 11/02/2022 EP20220211-0007 2022021100020 MUHAMMAD HASAN 20,500.0

HERWANTO
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
26 RD20220211-0010 11/02/2022 EP20220211-0012 2022021100029 TEE MENG SUN 138,610.0

CAPSUL
(PREKURSOR)
27 RD20220211-0012 11/02/2022 EP20220211-0011 2022021100031 NAURA SYAKIRA ARSYIDINATA 20,500.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
28 RD20220211-0013 11/02/2022 EP20220211-0013 2022021100032 AZZAHRA RIYANTO 382,990.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
R/ PROPYRETIC 160 MG SUPP 1.00 SUPP 9,973.00 9,973.00 0 1

(BPJS)
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ PICYN 750 MG INJ 2.00 VIAL 103,125.00 206,250.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
R/ CEFIXIME DRY 30 ML SYR 1.00 BTL 40,838.00 40,838.00 1 0
32 RD20220213-0004 13/02/2022 EP20220213-0003 2022021300004 YOSAN VRNANDA TOGATOROP 11,733.0

(BPJS)
33 RD20220213-0021 13/02/2022 EP20220213-0018 2022021300046 RINALDO PURBA 63,215.0
R/ METOCLOPRAMIDE 5 MG/ML 3.00 AMP 9,625.00 28,875.00 1 0

INJ
R/ CURCUMA FCT TAB 2.00 TAB 885.00 1,770.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

KAPLET
34 RD20220214-0036 14/02/2022 EP20220214-0035 2022021400062 ROSANTINA HUTABARAT 272,930.0
35 RD20220215-0001 15/02/2022 EP20220215-0001 2022021500001 NADYA EKA PUTRI 101,090.0
36 RD20220215-0002 15/02/2022 EP20220215-0002 2022021500002 ELKANA 395,992.0
37 RD20220215-0003 15/02/2022 EP20220215-0003 2022021500004 LISPIDA ROSTIKA 167,910.0

CAPSUL
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
38 RD20220215-0004 15/02/2022 EP20220215-0004 2022021500005 ROMARTA HALOHO 77,990.0

CAPSUL
39 RD20220215-0005 15/02/2022 EP20220215-0005 2022021500006 RICKY ZAMUSTI 86,090.0

TAB
40 RD20220215-0006 15/02/2022 EP20220215-0006 2022021500007 MUHAMMAD KEMAL 327,470.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
41 RD20220215-0007 15/02/2022 EP20220215-0007 2022021500008 RASHYA ALFAIZI 76,588.0
42 RD20220215-0008 15/02/2022 EP20220215-0008 2022021500009 INDRIANI 153,520.0

CAPSUL

(PREKURSOR)
43 RD20220215-0009 15/02/2022 EP20220215-0009 2022021500010 APRILLIA PASKAH ANASTASYA 78,190.0
BR SINURAT
44 RD20220215-0010 15/02/2022 EP20220215-0010 2022021500011 HENDRI RUDIANTO 64,168.0
45 RD20220217-0031 17/02/2022 EP20220217-0031 2022021700068 ALFREDO SINAGA 143,810.0

(PREKURSOR)
47 RD20220217-0033 17/02/2022 EP20220217-0032 2022021700071 ABDUL ROPI 305,800.0


(PREKURSOR)
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
49 RD20220217-0035 17/02/2022 EP20220217-0033 2022021700075 M IQBAL 63,140.0
50 RD20220217-0036 17/02/2022 EP20220217-0034 2022021700078 DESPIANA PITRI 175,440.0

(PREKURSOR)
51 RD20220217-0037 17/02/2022 EP20220217-0035 2022021700079 NOVIANTY NDURU 176,468.0

(PREKURSOR)
52 RD20220217-0038 17/02/2022 EP20220217-0036 2022021700080 ELFIRITA SIMATUPANG 78,190.0
53 RD20220217-0039 17/02/2022 EP20220217-0037 2022021700082 KAYANA YUMNA MUMTAZAH 97,763.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
54 RD20220217-0040 17/02/2022 EP20220217-0038 2022021700084 NORLELA 63,360.0

(BPJS)
55 RD20220217-0041 17/02/2022 EP20220217-0039 2022021700089 RIA RISVIANA 100,660.0

(PREKURSOR)

CAPSUL
56 RD20220217-0042 17/02/2022 EP20220217-0038 2022021700090 NORLELA 86,940.0
KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 5.00 TAB 2,600.00 13,000.00 0 1
57 RD20220218-0041 18/02/2022 EP20220218-0035 2022021800070 ROFINA PAKU 52,540.0

KAPLET
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
58 RD20220219-0001 19/02/2022 EP20220219-0001 2022021900004 GITA MARISKA BR TARIGAN 145,858.0

CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
59 RD20220219-0002 19/02/2022 EP20220219-0002 2022021900008 NURUL APRILIA 289,410.0

CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

(PREKURSOR)
60 RD20220219-0003 19/02/2022 EP20220219-0003 2022021900009 JAN PARUNTUNGAN RONO 88,350.0

HUTABARAT
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
61 RD20220220-0003 20/02/2022 EP20220220-0003 2022022000007 NOVI NOVRI YENTI 148,320.0

(PREKURSOR)
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
62 RD20220220-0004 20/02/2022 EP20220220-0005 2022022000009 ANGGUN RIDONA 20,190.0
63 RD20220220-0005 20/02/2022 EP20220220-0004 2022022000010 ANI HUTAHAYAN 65,876.0
R/ D 40 25 ML (OTSU) 2.00 FLS 12,813.00 25,626.00 0 1
R/ DEXTROSE 10 % INF 500 ML 1.00 FLS 7,275.00 7,275.00 1 0
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
65 RD20220220-0007 20/02/2022 EP20220220-0008 2022022000019 HALIMATUS SAKINAH 377,470.0

(PREKURSOR)
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
66 RD20220220-0008 20/02/2022 EP20220220-0007 2022022000020 FANOTONA YUBILA DAELI 155,540.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
67 RD20220220-0009 20/02/2022 EP20220220-0009 2022022000025 ADE CANDRA PUTRA 4,580.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
68 RD20220220-0010 20/02/2022 EP20220220-0010 2022022000029 NOVELINA SELES 155,540.0
LUMBANTORUAN

CAPSUL
(PREKURSOR)
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
69 RD20220221-0002 21/02/2022 EP20220221-0002 2022022100006 ANGELICA DEBORA 155,540.0

SIMANJUTAK

(PREKURSOR)
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
70 RD20220221-0003 21/02/2022 EP20220221-0004 2022022100009 SARWONO 100,660.0

CAPSUL
(PREKURSOR)
71 RD20220221-0006 21/02/2022 EP20220221-0006 2022022100013 DELIMA PUTRI MARBUN 217,903.0
R/ WING NEEDLE 25 G (3/4) 1.00 PCS 2,973.00 2,973.00 1 0
72 RD20220221-0007 21/02/2022 EP20220221-0005 2022022100014 TIOLINAR SIRUMAPEA 46,000.0

CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
73 RD20220221-0008 21/02/2022 EP20220221-0008 2022022100020 WELTINA MARPAUNG 28,880.0
74 RD20220221-0009 21/02/2022 EP20220221-0009 2022022100022 RODIAH YOSI 110,111.0


(PREKURSOR)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
75 RD20220221-0010 21/02/2022 EP20220221-0007 2022022100027 SUGIONO 107,485.0

(PREKURSOR)

CAPSUL

CAPSUL
R/ DEVIT 1000 IU 12.00 TAB 2,600.00 31,200.00 0 1
77 RD20220221-0012 21/02/2022 EP20220221-0014 2022022100034 BLASIUS 20,190.0
78 RD20220221-0013 21/02/2022 EP20220221-0013 2022022100035 SURYA DARMA LATURE 125,003.0

CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
79 RD20220221-0014 21/02/2022 EP20220221-0016 2022022100038 SUHERMAN 5,140.0
80 RD20220221-0015 21/02/2022 EP20220221-0015 2022022100040 JANWAR CANDRA SINUKABAN 80,603.0

TAB
CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
81 RD20220222-0002 22/02/2022 EP20220222-0002 2022022200006 295,275.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
82 RD20220222-0003 22/02/2022 EP20220222-0004 2022022200007 BAMBANG JUWITO 212,570.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
83 RD20220222-0004 22/02/2022 EP20220222-0005 2022022200009 PESMAWATI 154,575.0

CAPSUL
84 RD20220222-0005 22/02/2022 EP20220222-0007 2022022200011 FARID ASNGARI 315,870.0
85 RD20220222-0006 22/02/2022 EP20220222-0006 2022022200012 RIZKI AFRIANATA 51,820.0
86 RD20220222-0007 22/02/2022 EP20220222-0003 2022022200014 VERAWATI LUMBAN TOBING 175,859.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
87 RD20220222-0008 22/02/2022 EP20220222-0008 2022022200015 OBNIEL NICHOLAS MANURUNG 100,190.0
88 RD20220222-0009 22/02/2022 EP20220222-0010 2022022200016 BAYU SUKMA 85,140.0
89 RD20220222-0010 22/02/2022 EP20220222-0011 2022022200017 YAN ARDIMAN 28,040.0
90 RD20220222-0011 22/02/2022 EP20220222-0012 2022022200019 FEBY ERDINA 197,870.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
91 RD20220222-0012 22/02/2022 EP20220222-0013 2022022200020 IRFAN FADIL MAHENDRA 39,500.0
R/ CENDO FENICOL 1 % SALEP 1.00 FLS 39,500.00 39,500.00 0 0

MATA
92 RD20220222-0013 22/02/2022 EP20220222-0014 2022022200021 SHINTIA ELISRA 95,140.0
93 RD20220222-0014 22/02/2022 EP20220222-0015 2022022200022 JOHANES 323,770.0

TAB
94 RD20220222-0015 22/02/2022 EP20220222-0016 2022022200023 PERMATA SUCI 85,140.0
95 RD20220223-0018 23/02/2022 EP20220223-0016 2022022300032 ELVINA SARI BANGUN 10.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
96 RD20220224-0001 24/02/2022 EP20220224-0001 2022022400004 189,178.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
97 RD20220225-0001 25/02/2022 EP20220225-0001 2022022500003 DEVI HARYANTI SEMBIRING 387,358.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
98 RD20220226-0010 26/02/2022 EP20220226-0010 2022022600017 CHYNTIA PARHUSIP 3,880.0

KAPLET
99 RD20220226-0011 26/02/2022 EP20220226-0009 2022022600018 MUHAMMAD RONALDO 190,998.0
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
100 RD20220226-0012 26/02/2022 EP20220226-0011 2022022600019 SAHAT PARULIAN SIREGAR 462,870.0
101 RD20220226-0013 26/02/2022 EP20220226-0012 2022022600020 YULIA GUSTINA 120,140.0
102 RD20220226-0014 26/02/2022 EP20220225-0002 2022022600031 SESONIA KESYALIANI 3,880.0

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
103 RD20220226-0015 26/02/2022 EP20220226-0013 2022022600022 SHINTA YUNITA PUTRI 136,810.0

CAPSUL
104 RD20220226-0016 26/02/2022 EP20220226-0016 2022022600023 NOVITA ANGLELINA 35,715.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
105 RD20220226-0017 26/02/2022 EP20220226-0016 2022022600024 NOVITA ANGLELINA 9,973.0

(BPJS)
106 RD20220226-0018 26/02/2022 EP20220226-0015 2022022600025 RISNA PULUNGAN 119,080.0
107 RD20220226-0019 26/02/2022 EP20220226-0014 2022022600026 ALI AMRAN 197,070.0
108 RD20220226-0020 26/02/2022 EP20220226-0017 2022022600027 KINTAN HANNAN ASRAWI 128,040.0

DARMA

TAB
109 RD20220226-0021 26/02/2022 EP20220226-0018 2022022600028 DENTO 36,910.0

KAPLET
110 RD20220226-0022 26/02/2022 EP20220226-0019 2022022600032 ELISABETH EVI 141,860.0

KAPLET
R/ LANSOPRAZOLE 30 MG CAPS 10.00 CAP 2,027.00 20,270.00 1 0
111 RD20220227-0017 27/02/2022 EP20220227-0008 2022022700019 DIESEL SIMANJUNTAK 4,580.0

KAPLET
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
112 RD20220227-0019 27/02/2022 EP20220 2022022700024 DIAZ JOSHUA SIMAMORA 20,500.0

227-0009
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
115 RD20220228-0002 28/02/2022 EP20220228-0002 2022022800004 JESSICA ORLEE SIRAIT 105,463.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
116 RD20220228-0003 28/02/2022 EP20220228-0005 2022022800007 LENA MARTATI 3,880.0

KAPLET
117 RD20220228-0004 28/02/2022 EP20220228-0004 2022022800008 GRASELLA SESILIA SIMAMORA 20,500.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
118 RD20220228-0005 28/02/2022 EP20220228-0007 2022022800009 FADHILLA INAYAH.S 250,113.0
R/ SPORETIK SYRUP 100 MG/5ML 1.00 FLS 111,925.00 111,925.00 0 1
119 RD20220228-0006 28/02/2022 EP20220228-0006 2022022800011 FADHIL HAKIM.S 250,113.0
120 RD20220228-0007 28/02/2022 EP20220228-0008 2022022800012 SARDIMA HARAHAP 70,700.0

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
121 RD20220228-0008 28/02/2022 EP20220228-0003 2022022800014 WENDELINUS LIAN HEWEN 2,460.0
R/ METFORMIN 500 MG TAB 10.00 TAB 246.00 2,460.00 1 0
122 RD20220228-0011 28/02/2022 EP20220228-0003 2022022800017 WENDELINUS LIAN HEWEN 134,420.0

(PREKURSOR)
123 RI20220204-0018 04/02/2022 RI20220204-0002 RI20220204-0018 NATALIA NOPRIANTI BR 66,510.0

TARIGAN
R/ URSODEOXYCHOLIC ACID 250 3.00 CAP 6,237.00 18,711.00 1 0

MG
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

TARIGAN
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

MG
125 RI20220207-0024 07/02/2022 RI20220207-0004 RI20220207-0024 NOVRIATI SIMANUNGKALIT 305,970.0

KAPLET

(BPJS)

KAPLET

(BPJS)
Total Dokter DR. FELIX VALERIAN HALIM 17,189,519.0
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. GINA ARIANI, SP.PD
1 RI20220201-0006 01/02/2022 RI20220131-0002 RI20220201-0006 YULIANA MELI 116,850.0
2 RI20220201-0009 01/02/2022 RI20220129-0002 RI20220201-0009 TINJAU SINUKABAN 1,310.0
R/ SIMVASTATIN 20 MG TAB 1.00 TAB 1,283.00 1,283.00 1 0
R/ BICNAT TAB 3.00 TAB 9.00 27.00 1 0
R/ KSR TAB 2.00 TAB 4,050.00 8,100.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

(BPJS)
R/ SALIN 3 % 500 ML (OTSU) 1.00 FLS 38,828.00 38,828.00 0 1
R/ BICNAT TAB 3.00 TAB 9.00 27.00 1 0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ KSR TAB 2.00 TAB 4,050.00 8,100.00 0 1
9 RI20220202-0018 02/02/2022 RI20220202-0001 RI20220202-0018 JOHAN WIBOWO 548,071.0

PANGARIBUAN
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
R/ LAMETIC 4 MG INJ 2.00 AMP 42,240.00 84,480.00 0 1

R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(BPJS)

PANGARIBUAN

(PREKURSOR)

PANGARIBUAN
13 RI20220202-0034 02/02/2022 RI20220131-0002 RI20220202-0034 YULIANA MELI 885.0
R/ CURCUMA FCT TAB 1.00 TAB 885.00 885.00 0 1

PANGARIBUAN
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
17 RI20220203-0017 03/02/2022 RI20220129-0002 RI20220203-0017 TINJAU SINUKABAN 185.0

KAPLET
PANGARIBUAN
R/ SANMOL 500 MG TABLET 2.00 TAB 408.00 816.00 0 1

PANGARIBUAN
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1

PANGARIBUAN

PANGARIBUAN
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1

PANGARIBUAN

TARIGAN

PANGARIBUAN

R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

TARIGAN

MG
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

PANGARIBUAN

(PREKURSOR)
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
27 RI20220206-0007 06/02/2022 RI20220206-0001 RI20220206-0007 ROIDA SIHOTANG 37,098.0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

TARIGAN
R/ TRICHODAZOL 500 MG TAB 3.00 TAB 2,173.00 6,519.00 0 1

TARIGAN

PANGARIBUAN
R/ OPILAX 60 ML SYR 1.00 FLS 77,440.00 77,440.00 0 1

TARIGAN
R/ AQUADES 25 ML 125.00 CC 356.00 44,500.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

PANGARIBUAN

TARIGAN
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

MG
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

PANGARIBUAN
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1

PANGARIBUAN
R/ IMUNVIT KAPLET 7.00 KAPLET 10,000.00 70,000.00 0 0

TARIGAN
39 RI20220207-0012 07/02/2022 RI202202 RI20220207-0012 INNA 152,822.0

07-0003
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

INJ (BPJS)
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1

KAPLET
TABLET
R/ KANDISTATIN DROP 1.00 FLS 52,938.00 52,938.00 0 1

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
40 RI20220207-0015 07/02/2022 RI20220207-0003 RI20220207-0015 INNA 1,770.0
41 RI20220207-0021 07/02/2022 RI20220207-0003 RI20220207-0021 INNA 13,333.0
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
42 RI20220208-0002 08/02/2022 RI20220207-0003 RI20220208-0002 INNA 7,157.0
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
43 RI20220208-0005 08/02/2022 RI20220207-0003 RI20220208-0005 INNA 50,882.0

CAPSUL
TABLET

INJ (BPJS)
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
44 RI20220208-0007 08/02/2022 RI20220208-0001 RI20220208-0007 ANDIKA PUTRA 556,420.0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
45 RI20220208-0008 08/02/2022 RI20220207-0005 RI20220208-0008 ARI SAPUTRA RAMBE 96,505.0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

KAPLET
TARIGAN
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

MG
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
48 RI20220208-0018 08/02/2022 RI20220208-0002 RI20220208-0018 POLMAN MANALU 29,597.0
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

KAPLET
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
50 RI20220208-0021 08/02/2022 RI20220207-0003 RI20220208-0021 INNA 29,700.0
R/ FLUCONAZOLE 150 MG TAB 1.00 TAB 29,700.00 29,700.00 1 0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
52 RI20220208-0026 08/02/2022 RI20220207-0004 RI20220208-0026 NOVRIATI SIMANUNGKALIT 885.0
R/ FREGO 5 MG TAB 1.00 TAB 8,448.00 8,448.00 0 0
55 RI20220209-0001 09/02/2022 RI20220208-0003 RI20220209-0001 CHRISTOPER HP SITANGGANG 98,441.0
R/ AZITHROMYCIN 500 MG 1.00 KAPLET 6,930.00 6,930.00 1 0

KAPLET

CAPSUL
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ TRANSOFIX 1.00 PCS 19,600.00 19,600.00 0 1
R/ AQUADEST 1000 ML 1.00 FLS 32,134.00 32,134.00 1 0

TARIGAN
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

MG

KAPLET
61 RI20220209-0011 09/02/2022 RI20220207-0003 RI20220209-0011 INNA 13,333.0
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ CEFTRIAXONE 1 GR INJ 2.00 VIAL 13,368.00 26,736.00 1 0
R/ OMEPRAZOLE 20 MG CAP 1.00 CAP 742.00 742.00 1 0

KAPLET
63 RI20220209-0013 09/02/2022 RI20220207-0003 RI20220209-0013 INNA 37,580.0

CAPSUL
KAPLET
TABLET
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

TARIGAN

NEEDLE) ONEMED
R/ AMINOFUSIN HEPAR 500 ML 1.00 FLS 246,000.00 246,000.00 1 0

INF
R/ STOMACH TUBE NO. 16 1.00 PCS 38,961.00 38,961.00 0 1
67 RI20220209-0021 09/02/2022 RI20220209-0001 RI20220209-0021 RAYA SIHOMBING 94,428.0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

(BPJS)
TARIGAN
R/ IBUPROFEN 400 MG TAB 1.00 TAB 514.00 514.00 1 0


KAPLET
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1

TARIGAN
R/ TRANSOFIX 1.00 PCS 19,600.00 19,600.00 0 1

KAPLET
74 RI20220209-0031 09/02/2022 RI20220207-0003 RI20220209-0031 INNA 675.0

R/ VITAMIN B6 (PYRIDOXINE) 5.00 TAB 135.00 675.00 1 0
TAB

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
75 RI20220209-0033 09/02/2022 RI20220209-0002 RI20220209-0033 EKA ROSIANA 102,916.0

KAPLET
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0

(BPJS)
(NARKOTIKA)
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ SPASMINAL TABLET 1.00 TAB 817.00 817.00 0 1
82 RI20220210-0006 10/02/2022 RI20220207-0003 RI20220210-0006 INNA 685.0
R/ COTRIMOXAZOLE 480 MG 1.00 TAB 550.00 550.00 1 0

TABLET
TAB

CAPSUL
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0

(BPJS)
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

TARIGAN
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

INJ
(BPJS)
R/ RL 500 ML INF 5.00 FLS 9,766.00 48,830.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1
R/ CEFTRIAXONE 1 GR INJ 2.00 VIAL 13,368.00 26,736.00 1 0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

KAPLET

KAPLET

KAPLET
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

CAPSUL
KAPLET

(BPJS)
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1

KAPLET
(BPJS)
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non
Formula
91 RI20220210-0017 10/02/2022 RI20220207-0003 RI20220210-0017 INNA 48,284.0

TAB
CAPSUL
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

TABLET
KAPLET

(BPJS)
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
(NARKOTIKA)
96 RI20220210-0028 10/02/2022 RI20220207-0003 RI20220210-0028 INNA 29,700.0

TARIGAN


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ KSR TAB 1.00 TAB 4,050.00 4,050.00 0 1
101 RI20220210-0037 10/02/2022 RI20220207-0003 RI20220210-0037 INNA 10,626.0
102 RI20220210-0038 10/02/2022 RI20220207-0003 RI20220210-0038 INNA 2,025.0
R/ VITAMIN B6 (PYRIDOXINE) 15.00 TAB 135.00 2,025.00 1 0

TAB
103 RI20220210-0042 10/02/2022 RI20220207-0003 RI20220210-0042 INNA 13,720.0
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1

(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

KAPLET
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1

KAPLET


(BPJS)
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET

KAPLET

KAPLET
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1
109 RI20220211-0008 11/02/2022 RI20220207-0003 RI20220211-0008 INNA 38,894.0

KAPLET

TAB
TABLET

CAPSUL

KAPLET
113 RI20220211-0015 11/02/2022 RI20220207-0003 RI20220211-0015 INNA 83,088.0

TABLET
CAPSUL

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL
R/ DEVIT 1000 IU 6.00 TAB 2,600.00 15,600.00 0 1

(BPJS)
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

CAPSUL
120 RI20220212-0020 12/02/2022 RI20220212-0002 RI20220212-0020 ANANDA DAME SIHOMBING 136,610.0

KAPLET
R/ LEVOFLOXACIN 500MG/100 ML 1.00 FLS 110,000.00 110,000.00 1 0
INF
CAPSUL

KAPLET
CAPSUL
INF
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

123 RI20220213-0017 13/02/2022 RI20220213-0002 RI20220213-0017 SILVIA MAHESTI 225,786.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
124 RI20220213-0021 13/02/2022 RI20220213-0003 RI20220213-0021 NADA SUHALLAH 47,664.0

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

CAPSUL
125 RI20220213-0022 13/02/2022 RI20220213-0004 RI20220213-0022 ASIMA FLORENTINA MANIK 888,394.0

CAPSUL
R/ RESFAR 25 ML 2.00 FLS 280,192.00 560,384.00 0 1

INF
KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

(PREKURSOR)
128 RI20220214-0010 14/02/2022 RI20220213-0005 RI20220214-0010 RINALDO PURBA 32,715.0

KAPLET

INJ
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL

INF
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET

CAPSUL
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

CAPSUL

KAPLET
R/ AQUADES 25 ML 125.00 CC 356.00 44,500.00 0 1
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(GAMMEX) NO. 7
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
R/ ASERING 500 ML INF 1.00 FLS 10,800.00 ### 0 1

CAPSUL

KAPLET
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0
R/ NS 0.9 100 ML (PIGGY BACK) 1.00 FLS 19,430.00 19,430.00 1 0
R/ DEVIT 1000 IU 2.00 TAB 2,600.00 5,200.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
CAPSUL
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

INJ
KAPLET
R/ NALD 23 (ONEMED) 2.00 PCS 1,813.00 3,626.00 0 1
R/ DEVIT 1000 IU 2.00 TAB 2,600.00 5,200.00 0 1
R/ ACETYLCISTEINE 200MG/VIAL 1.00 VIAL 280,192.00 280,192.00 1 0

R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NALD 23 (ONEMED) 2.00 PCS 1,813.00 3,626.00 0 1

(NARKOTIKA)
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1
157 RI20220215-0018 15/02/2022 RI20220215-0003 RI20220215-0018 HOKKOP SIMANJUNTAK 52,855.0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
158 RI20220216-0001 16/02/2022 RI20220215-0005 RI20220216-0001 RINA NUR SAFRIDA 406,094.0
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
159 RI20220216-0002 16/02/2022 RI20220215-0004 RI20220216-0002 AMIRA RIZKI PUTRI 247,101.0
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

CAPSUL
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

1GR/100 ML
KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL
1GR/100 ML
KAPLET
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

CAPSUL

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

(NARKOTIKA)
KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

CAPSUL
R/ ONDANSETRON 8 MG INJ 2.00 AMP 10,000.00 20,000.00 1 0
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ IMUNVIT PLUS KAPLET 1.00 KAPLET 13,500.00 13,500.00 0 1
R/ PANLOC INJ 2.00 VIAL 211,200.00 422,400.00 0 1
R/ VIVENA INJ 2.00 VIAL 73,000.00 146,000.00 0 1
170 RI20220216-0015 16/02/2022 RI20220216-0001 RI20220216-0015 WANRA HUTAPEA 66,468.0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

INJ
R/ DEVIT 1000 IU 21.00 TAB 2,600.00 54,600.00 0 1

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(NARKOTIKA)
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

INJ (BPJS)
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1

500MG/5ML
R/ NEO K INJ 3.00 AMP 17,459.00 52,377.00 0 1

KAPLET
178 RI20220216-0031 16/02/2022 RI20220213-0005 RI20220216-0031 RINALDO PURBA 555.0

KAPLET
179 RI20220216-0033 16/02/2022 RI20220216-0004 RI20220216-0033 MIFTA WAHYU PUTRI 25,770.0
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
CAPSUL
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NEO K INJ 3.00 AMP 17,459.00 52,377.00 0 1

500MG/5ML

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ PANLOC INJ 1.00 VIAL 211,200.00 211,200.00 0 1
R/ VIVENA INJ 2.00 VIAL 73,000.00 146,000.00 0 1
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1
185 RI20220217-0007 ### RI20220216-0004 RI20220217-0007 MIFTA WAHYU PUTRI 36,570.0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

INJ

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

KAPLET

INJ
189 RI20220217-0014 17/02/2022 RI20220216-0001 RI20220217-0014 WANRA HUTAPEA 555.0

KAPLET
192 RI20220217-0018 17/02/2022 RI20220217-0001 RI20220217-0018 MARIA ANA LIPAT 217,379.0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

1GR/100 ML
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
193 RI20220217-0019 17/02/2022 RI20220217-0003 RI20220217-0019 ANA MARIANA 162,741.0

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1
EFFERVESCENT

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ DEXAMETHASON 5MG/1ML INJ 1.00 AMP 3,003.00 3,003.00 1 0
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
196 RI20220217-0022 17/02/2022 RI20220217-0004 RI20220217-0022 JEFRI ROLLI RICHARDO 62,967.0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ TRANSOFIX 1.00 PCS 19,600.00 19,600.00 0 1
R/ KCL 7.46% 25 ML 1.00 FLS 11,686.00 11,686.00 0 1
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

INJ
KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ SIMVASTATIN 10 MG TAB 1.00 TAB 480.00 480.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
208 RI20220218-0012 18/02/2022 RI20220217-0002 RI20220218-0012 FRENTRY SIHOMBING 50,219.0

KAPLET
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

INJ (BPJS)
210 RI20220218-0015 18/02/2022 RI20220218-0001 RI20220218-0015 RANI LESTARI MANURUNG 273,815.0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
222 RI20220218-0033 18/02/2022 RI20220216-0004 RI20220218-0033 MIFTA WAHYU PUTRI 885.0
223 RI20220218-0035 18/02/2022 RI20220218-0004 RI20220218-0035 ANCUS PARULIAN SILALAHI 293,843.0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

1GR/100 ML

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ LEVOFLOXACIN 750 MG INF 1.00 FLS 100,000.00 100,000.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
KAPLET
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
226 RI20220219-0004 19/02/2022 RI20220217-0002 RI20220219-0004 FRENTRY SIHOMBING 1,158,644.0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ RESFAR 25 ML 2.00 FLS 280,192.00 560,384.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
227 RI20220219-0005 19/02/2022 RI20220217-0001 RI20220219-0005 MARIA ANA LIPAT 1,124,545.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685

Jenis
resep :
Rawat
Inap
Formula Non Formula
R/ RESFAR 25 ML 2.00 FLS 280,192.00 560,384.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET

(BPJS)

INJ
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

KAPLET

INJ

KAPLET
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ SIMVASTATIN 10 MG TAB 1.00 TAB 480.00 480.00 1 0

R/ KSR TAB 1.00 TAB 4,050.00 4,050.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
236 RI20220219-0018 19/02/2022 RI20220219-0001 RI20220219-0018 TARULI SINAGA 110,467.0

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NOVORAPID FLEXPEN 1.00 VIAL 81,364.00 81,364.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
243 RI20220219-0029 19/02/2022 RI20220217-0001 RI20220219-0029 MARIA ANA LIPAT 550.0
244 RI20220219-0032 19/02/2022 RI20220219-0005 RI20220219-0032 WANSI SITUMORANG 36,855.0

CAPSUL

R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
253 RI20220220-0005 20/02/2022 RI20220216-0001 RI20220220-0005 WANRA HUTAPEA 660.0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
254 RI20220220-0006 20/02/2022 RI20220219-0003 RI20220220-0006 ERIKSON SIMORANGKIR 5,373.0

INJ (BPJS)
TAB
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

INJ
KAPLET
R/ RL 500 ML INF 4.00 FLS 9,766.00 39,064.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NALD 23 (ONEMED) 3.00 PCS 1,813.00 5,439.00 0 1

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ RESFAR 25 ML 2.00 FLS 280,192.00 560,384.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 2.00 FLS 280,192.00 560,384.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

KAPLET
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

(BPJS)
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

(BPJS)
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

KAPLET

KAPLET
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
271 RI20220220-0035 20/02/2022 RI20220220-0001 RI20220220-0035 ANI HUTAHAYAN 122,170.0

INJ
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1
EFFERVESCENT
R/ RAMIPRIL 5 MG TAB (BPJS) 1.00 TAB 857.00 857.00 1 0

(BPJS)
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ D 40 25 ML (OTSU) 2.00 FLS 12,813.00 25,626.00 0 1
R/ KSR TAB 2.00 TAB 4,050.00 8,100.00 0 1

KAPLET

INJ (BPJS)
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1

R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 2.00 TAB 2,600.00 5,200.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ NACL 0.9 % 500 ML INF 4.00 FLS 13,333.00 53,332.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ NACL 0.9 % 500 ML INF 4.00 FLS 13,333.00 53,332.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ NACL 0.9 % 500 ML INF 4.00 FLS 13,333.00 53,332.00 1 0
R/ NACL 0.9 % 500 ML INF 4.00 FLS 13,333.00 53,332.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

(BPJS)
R/ NACL 0.9 % 500 ML INF 4.00 FLS 13,333.00 53,332.00 1 0
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
(BPJS)
KAPLET
R/ DEVIT 1000 IU 1.00 TAB 2,600.00 2,600.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(BPJS)
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT

(GAMMEX) NO. 7

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ KSR TAB 2.00 TAB 4,050.00 8,100.00 0 1

INJ (BPJS)
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ MEMUCIL 600 MG 3.00 TAB 14,000.00 42,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ KSR TAB 1.00 TAB 4,050.00 4,050.00 0 1
308 RI20220222-0002 22/02/2022 RI20220221-0004 RI20220222-0002 SULAIMAN 26,939.0
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

KAPLET
309 RI20220222-0007 22/02/2022 RI20220221-0004 RI20220222-0007 SULAIMAN 63,360.0

(BPJS)
310 RI20220222-0008 22/02/2022 RI20220221-0004 RI20220222-0008 SULAIMAN 13,993.0
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
311 RI20220222-0011 22/02/2022 RI20220221-0004 RI20220222-0011 SULAIMAN 18,688.0
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1

KAPLET

(GAMMEX) NO. 7
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

(GAMMEX) NO. 7
R/ NACL 0.9 % 500 ML INF 2.00 FLS 13,333.00 26,666.00 1 0
R/ KSR TAB 2.00 TAB 4,050.00 8,100.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
314 RI20220222-0017 22/02/2022 RI20220221-0004 RI20220222-0017 SULAIMAN 50,188.0
R/ AQUADE 25.00 CC 356.00 8,900.00 0 1

S 25 ML

(GAMMEX) NO. 7
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1

KAPLET
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
(GAMMEX) NO. 7

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(GAMMEX) NO. 7
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

(BPJS)
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
(GAMMEX) NO. 7
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

(GAMMEX) NO. 7

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

(GAMMEX) NO. 7
KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ OMEPRAZOLE 20 MG CAP 1.00 CAP 742.00 742.00 1 0

(GAMMEX) NO. 7
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

(BPJS)
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
324 RI20220222-0030 22/02/2022 RI20220221-0004 RI20220222-0030 SULAIMAN 125,361.0

(GAMMEX) NO. 7
325 RI20220222-0031 22/02/2022 RI20220221-0004 RI20220222-0031 SULAIMAN 2,655.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET

KAPLET
331 RI20220222-0040 22/02/2022 RI20220221-0004 RI20220222-0040 SULAIMAN 20,790.0

KAPLET

CAPSUL

CAPSUL

CAPSUL

CAPSUL
337 RI20220222-0047 22/02/2022 RI20220221-0004 RI20220222-0047 SULAIMAN 885.0
338 RI20220223-0001 23/02/2022 RI20220221-0004 RI20220223-0001 SULAIMAN 12,786.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
340 RI20220223-0010 23/02/2022 RI20220221-0004 RI20220223-0010 SULAIMAN 8,132.0

KAPLET

CAPSUL
R/ KSR TAB 1.00 TAB 4,050.00 4,050.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET

CAPSUL

R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ DEVIT 1000 IU 7.00 TAB 2,600.00 18,200.00 0 1
R/ RAMIPRIL 5 MG TAB (BPJS) 7.00 TAB 857.00 5,999.00 1 0

CAPSUL
R/ DEVIT 1000 IU 15.00 TAB 2,600.00 39,000.00 0 1

CAPSUL
R/ ASPILET 80 MG TAB 5.00 TAB 729.00 3,645.00 0 0
R/ DEVIT 1000 IU 15.00 TAB 2,600.00 39,000.00 0 1


CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(NARKOTIKA)

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
CAPSUL

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1


CAPSUL
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 15.00 TAB 2,600.00 39,000.00 0 1
R/ DEVIT 1000 IU 9.00 TAB 2,600.00 23,400.00 0 1
R/ DEVIT 1000 IU 9.00 TAB 2,600.00 23,400.00 0 1

CAPSUL
367 RI20220225-0001 25/02/2022 RI20220224-0002 RI20220225-0001 RIA RINDI SARI 310,366.0

KAPLET

INJ
CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

(GAMMEX) NO. 7

KAPLET
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
374 RI20220225-0013 25/02/2022 RI20220225-0001 RI20220225-0013 YANUARI 7,150.0
375 RI20220225-0014 25/02/2022 RI20220225-0001 RI20220225-0014 YANUARI 54,625.0
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
376 RI20220225-0015 25/02/2022 RI20220225-0001 RI20220225-0015 YANUARI 20,533.0

R/ PRONALGES SUPPO 1.00 SUPP 20,533.00 20,533.00 0 1
377 RI20220225-0017 25/02/2022 RI20220225-0002 RI20220225-0017 FENTY LISTIJAWATI 424,762.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ ISOSORBID DINITRAT 5 MG 1.00 TAB 162.00 162.00 1 0

TAB
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ ASCORBIT ACID 1000 MG/5 ML 2.00 AMP 20,000.00 40,000.00 1 0

INJ
378 RI20220225-0018 25/02/2022 RI20220225-0001 RI20220225-0018 YANUARI 51,150.0

R/ ELEKTRODA 3M RED DOT 2239
DWS 5.00 PCS 1,430.00 7,150.00 0 1
379 RI20220225-0019 25/02/2022 RI20220225-0001 RI20220225-0019 YANUARI 614,524.0

R/ GELAFUSAL 500 ML INF 2.00 FLS 175,000.00 350,000.00 0 1
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
R/ NALD 18 (ONEMED) 1.00 PCS 861.00 861.00 1 0

NEEDLE) ONEMED
1,5 ML
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0
R/ NOREPINEPHRINE 4MG/4ML 1.00 AMP 37,500.00 37,500.00 1 0

INJ (BPJS)
R/ THREE WAY STOP CO-CKS 1.00 PCS 31,460.00 31,460.00 0 1
380 RI20220226-0001 26/02/2022 RI20220225-0001 RI20220226-0001 YANUARI 32,400.0

CAPSUL
382 RI20220226-0004 26/02/2022 RI20220225-0001 RI20220226-0004 YANUARI 62,417.0
R/ AQUADES 25 ML 3.00 CC 356.00 1,068.00 0 1
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
383 RI20220226-0005 26/02/2022 RI20220225-0001 RI20220226-0005 YANUARI 21,600.0

384 RI20220226-0006 26/02/2022 RI20220225-0001 RI20220226-0006 YANUARI 67,500.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
385 RI20220226-0007 26/02/2022 RI20220225-0001 RI20220226-0007 YANUARI 31,600.0

500MG/5ML
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

INJ
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
388 RI20220226-0011 26/02/2022 RI20220225-0001 RI20220226-0011 YANUARI 854,147.0
R/ GUEDEL NASAL NO. 5 1.00 PCS 132,813.00 132,813.00 0 1
R/ RECOFOL INJEKSI 1.00 AMP 139,335.00 139,335.00 0 1
R/ EPINEPHRINE INJ 1.00 AMP 12,160.00 12,160.00 1 0

(GAMMEX) NO. 7
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
R/ EPHEDRIN HCL INJ (PREK) 2.00 AMP 5,896.00 11,792.00 0 0
R/ D 40 25 ML (OTSU) 4.00 FLS 12,813.00 51,252.00 0 1

R/ NALD 18 ( TERUMO) 2.00 PCS 4,568.00 9,136.00 0 1
R/ ATRACURIUM BESILATE 50 2.00 AMP 57,750.00 115,500.00 1 0

MG/5 ML INJEKSI
R/ SEDACUM INJ 15MG/3ML 3.00 CC 25,912.00 77,736.00 0 0

(PSIKOTROPIKA
R/ ETT SIZE 7.5 RUSCH + BALON 1.00 PCS 84,500.00 84,500.00 1 0
R/ SUCTION CATHETHER NO. 16 1.00 PCS 8,712.00 8,712.00 0 1
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1
389 RI20220226-0012 26/02/2022 RI20220225-0001 RI20220226-0012 YANUARI 7,150.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
390 RI20220226-0013 26/02/2022 RI20220225-0001 RI20220226-0013 YANUARI 128,130.0
R/ D 40 25 ML (OTSU) 10.00 FLS 12,813.00 128,130.00 0 1
392 RI20220226-0015 26/02/2022 RI20220225-0002 RI20220226-0015 FENTY LISTIJAWATI 294.0
R/ FUROSEMIDE 40 MG TAB 1.00 TAB 294.00 294.00 1 0

CAPSUL
397 RI20220227-0006 27/02/2022 RI20220227-0001 RI20220227-0006 YANCE MAURICE MANURUNG 97,972.0

CAPSUL
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

R/ BICNAT TAB 3.00 TAB 203.00 609.00 1 0
R/ NALD 26 (ONEMED) 2.00 PCS 660.00 1,320.00 0 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

INJ
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ FAVIKAL 6.00 TAB 21,120.00 126,720.00 0 1

200 MG
R/ SURFLO
TABLET NO. 20 VENFLON 2.00 PCS 22,680.00 45,360.00 1 0
R/ NACL 0.9 % 500 ML INF 6.00 FLS 13,333.00 79,998.00 1 0
R/ TRANSOFIX 2.00 PCS 19,600.00 39,200.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1

CAPSUL

INJ
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ BICNAT TAB 3.00 TAB 203.00 609.00 1 0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0

INJ
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(GAMMEX) NO. 7
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

(BPJS)

INJ
406 RJ20220202-0003 02/02/2022 OP20220202-0001 2022020200006 LAURENTIUS BALAMAKIN 2,775.0

KAPLET
407 RJ20220202-0006 02/02/2022 OP20220202-0012 2022020200012 MEGAWATI SIMANJUNTAK 368,356.0
408 RJ20220203-0002 03/02/2022 OP20220203-0001 2022020300003 MEGAWATI SIMANJUNTAK 185,010.0
R/ ATORVASTATIN 20 MG TAB 30.00 TAB 6,167.00 185,010.00 1 0
409 RJ20220203-0004 03/02/2022 OP20220203-0003 2022020300006 MEI RANDA PAKPAHAN 8,085.0

KAPLET
410 RJ20220205-0001 05/02/2022 OP20220205-0005 2022020500002 ALLFIL REZKY ANDRIAL 15,975.0
411 RJ20220207-0011 07/02/2022 OP20220207-0017 2022020700018 NELLY SITINJAK 76,434.0

CAPSUL

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
412 RJ20220207-0014 07/02/2022 OP20220207-0018 2022020700023 IWAN SUMARNA 7,329.0
413 RJ20220208-0002 08/02/2022 OP20220208-0002 2022020800004 HENDRA 5,140.0
414 RJ20220208-0004 08/02/2022 OP20220208-0001 2022020800006 NURMA PARHUSIP 13,275.0
416 RJ20220209-0007 09/02/2022 OP20220209-0006 2022020900009 TAMBA TUA SIHOMBING 40,035.0

CAPSUL
417 RJ20220210-0003 10/02/2022 OP20220210-0005 2022021000004 JOHAN WIBOWO 70,000.0

PANGARIBUAN
418 RJ20220212-0003 12/02/2022 OP20220212-0002 2022021200005 YESAYA ZAI 47,650.0

CAPSUL
KAPLET
419 RJ20220212-0004 12/02/2022 OP20220212-0007 2022021200006 ERNAWATI MANIK 17,020.0
420 RJ20220214-0001 14/02/2022 OP20220214-0002 2022021400001 AMINAH 91,059.0
421 RJ20220214-0002 14/02/2022 OP20220214-0003 2022021400002 NOVRIATI SIMANUNGKALIT 8,850.0
422 RJ20220214-0003 14/02/2022 OP20220214-0002 2022021400003 AMINAH 497,424.0

R/ NOVORAPID FLEXPEN 4.00 VIAL 81,364.00 325,456.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
423 RJ20220214-0004 14/02/2022 OP20220214-0005 2022021400004 NURLELA 8,981.0
424 RJ20220214-0009 14/02/2022 OP20220214-0010 2022021400012 ANDIKA PUTRA 507,340.0
R/ ALPRAZOLAM 0,5 MG TAB 3.00 TAB 790.00 2,370.00 0 0

(PSI)

KAPLET
426 RJ20220214-0011 14/02/2022 OP20220214-0011 2022021400013 ROIDA SIHOTANG 85,984.0
427 RJ20220216-0006 16/02/2022 OP20220216-0005 2022021600006 TAHI RIANTO HENRIK PURBA 115,500.0
R/ ARDIUM 500 MG 15.00 TAB 7,700.00 115,500.00 0 1
428 RJ20220216-0008 16/02/2022 OP20220216-0007 2022021600012 NURLIANA BUTARBUTAR 4,650.0
R/ CLONIDINE 0.15 MG TAB 15.00 TAB 310.00 4,650.00 1 0
429 RJ20220216-0009 16/02/2022 OP20220216-0008 2022021600010 MUSA SILABAN 16,975.0

KAPLET
430 RJ20220216-0011 16/02/2022 OP20220216-0011 2022021600014 NESRY PURBA 2,058.0
R/ FUROSEMIDE 40 MG TAB 7.00 TAB 294.00 2,058.00 1 0
432 RJ20220217-0002 17/02/2022 OP20220217-0002 2022021700003 SUDIN 8,175.0

433 RJ20220217-0003 17/02/2022 OP20220217-0003 2022021700006 INNA 61,188.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

TABLET
434 RJ20220217-0005 17/02/2022 OP20220217-0006 2022021700008 SEPTRIDA DAMANIK 591,885.0
R/ FREGO 5 MG TAB 15.00 TAB 8,448.00 126,720.00 0 0
435 RJ20220217-0006 17/02/2022 OP20220217-0007 2022021700011 FURI NINGSIH 1,850.0

KAPLET
436 RJ20220218-0002 18/02/2022 OP20220218-0002 2022021800003 MULLER SITORUS 54,781.0
437 RJ20220219-0003 19/02/2022 OP20220219-0004 2022021900005 ABDUL ROPI 233,481.0

(PSIKOTROPIKA)
438 RJ20220219-0004 19/02/2022 OP20220219-0001 2022021900008 ERIKSON SIMORANGKIR 74,051.0

INJ (BPJS)
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
440 RJ20220221-0003 21/02/2022 OP20220221-0007 2022022100003 TRIHENMOI SINAGA 236,551.0

(PSIKOTROPIKA)
441 RJ20220221-0010 21/02/2022 OP20220221-0014 2022022100010 NURLELA 5,310.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
442 RJ20220222-0003 22/02/2022 OP20220222-0003 2022022200003 HERI KUSTIANTO 388,712.0
R/ GASTROLAN CAPS 7.00 CAP 18,226.00 127,582.00 0 1
443 RJ20220222-0004 22/02/2022 OP20220222-0004 2022022200004 DINAR RISNAWATI 16,142.0
444 RJ20220222-0005 22/02/2022 OP20220222-0004 2022022200005 DINAR RISNAWATI 53,038.0
445 RJ20220223-0004 23/02/2022 OP20220223-0005 2022022300005 NESRY PURBA 8,850.0
446 RJ20220223-0007 23/02/2022 OP20220223-0007 2022022300008 HOKKOP SIMANJUNTAK 5,820.0

KAPLET
447 RJ20220223-0008 23/02/2022 OP20220223-0008 2022022300009 TAHI RIANTO HENRIK PURBA 13,275.0
448 RJ20220223-0009 23/02/2022 OP20220223-0010 2022022300010 MUSA SILABAN 71,220.0

MG
451 RJ20220223-0012 23/02/2022 OP20220223-0011 2022022300013 RIZKI AFRIANATA 190,180.0

R/ MAXTAN 500 MG TABLET 20.00 TAB 1,784.00 35,680.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ KOLKISIN 0.5 MG TABLET 15.00 TAB 4,000.00 60,000.00 1 0
452 RJ20220223-0013 23/02/2022 OP20220223-0013 2022022300014 HERMINA BR SIBARANI 5,820.0

KAPLET
453 RJ20220224-0003 24/02/2022 OP20220224-0003 2022022400003 FURI NINGSIH 106,575.0

MG
454 RJ20220224-0004 24/02/2022 OP20220224-0004 2022022400008 ALFONSUS PARHUSIP 108,405.0
455 RJ20220225-0007 25/02/2022 OP20220225-0009 2022022500008 JAN SIRAIT 13,020.0
456 RJ20220225-0008 25/02/2022 OP20220225-0012 2022022500009 ERIKSON SIMORANGKIR 1,925.0
457 RJ20220225-0010 25/02/2022 OP20220225-0010 2022022500013 MULLER SITORUS 65,220.0
R/ ZEMINDO 60 ML SYR 1.00 BTL ### 52,800.00 0 1
458 RJ20220226-0002 26/02/2022 OP20220226-0004 2022022600002 RINALDO PURBA 5,310.0
Total Dokter DR. GINA ARIANI, SP.PD 60,538,562.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. SHINLY MEIVINITA GINTING
1 RD20220201-0003 01/02/2022 EP20220201-0003 2022020100004 MUHAMMAD YUSUF LUBIS 204,966.0
2 RD20220201-0004 01/02/2022 EP20220201-0002 2022020100005 TEGAR TRI ATMAJA 20,500.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
3 RD20220201-0005 01/02/2022 EP20220201-0004 2022020100007 SERTA NURCAHAYA 8,158.0

HUTAURUK
4 RD20220203-0013 03/02/2022 EP20220203-0012 2022020300015 ROHANA BUTAR- BUTAR 272,516.0
R/ BUSCOPAN TAB 10 MG 6.00 TAB 4,398.00 26,388.00 0 1
5 RD20220203-0014 03/02/2022 EP20220203-0013 2022020300016 BETTY PAKPAHAN 4,741.0

KAPLET
6 RD20220203-0015 03/02/2022 EP20220203-0014 2022020300017 ANDI KUSWORO 291,788.0
7 RD20220203-0016 03/02/2022 EP20220203-0015 2022020300018 ADITYA CHANDRA 208,744.0

8 RD20220203-0017 03/02/2022 EP20220203-0016 2022020300019 GRACELESA AMORA SITORUS 47,105.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ D5 + 1/4 NS 500 ML ( WIDA ) 1.00 FLS 23,005.00 23,005.00 0 1
9 RD20220203-0018 03/02/2022 EP20220203-0017 2022020300021 HASIAN SIMATUPANG 178,530.0
10 RD20220203-0019 03/02/2022 EP20220203-0018 2022020300022 PITRA PRATAMA GURUSINGA 11,242.0
R/ SANMOL 500 MG TABLET 9.00 TAB 1.00 408.00 11,242.00 0 1
METHYLPREDNISOLONE 4 MG 6.00 TAB 595.00 0.00 1 0

TAB
CETIRIZINE 10 MG TAB 3.00 TAB 1,000.00 0.00 1 0
11 RD20220203-0020 03/02/2022 EP20220203-0019 2022020300023 ANDIKA PUTRA 266,472.0
12 RD20220204-0004 04/02/2022 EP20220204-0005 2022020400011 INNA 4,020.0
13 RD20220204-0005 04/02/2022 EP20220204-0006 2022020400012 BETI LISTITE 205,520.0
15 RD20220204-0007 04/02/2022 EP20220204-0007 2022020400014 KAILA PEPAYOSA HUTASOIT 32,274.0
R/ D5 + 1/4 NS 500 ML ( WIDA ) 1.00 FLS 23,005.00 23,005.00 0 1

(BPJS)
16 RD20220204-0008 04/02/2022 EP20220204-0009 2022020400016 REVA ARAFAH FADILAH PUTRI 120,002.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
17 RD20220204-0009 04/02/2022 EP20220204-0008 2022020400019 WARSONO 24,940.0

KAPLET
18 RD20220204-0010 04/02/2022 EP20220204-0010 2022020400020 ROSMAWATI NAPITUPULU 2,600.0

KAPLET
19 RD20220204-0011 04/02/2022 EP20220204-0011 2022020400021 CHRISTIN MEGAWATY 92,773.0

SIREGAR
20 RD20220204-0012 04/02/2022 EP20220204-0012 2022020400022 SITI HARYANTI 255,910.0
R/ BENOSON M 5 GR CREAM 2.00 TUBE 75,625.00 151,250.00 0 1
21 RD20220204-0013 04/02/2022 EP20220204-0013 2022020400023 KAMIL 29,619.0

(PREKURSOR)
22 RD20220204-0014 04/02/2022 EP20220204-0014 2022020400024 HAMDANI PRABOWO 87,474.0

(PREKURSOR)
23 RD20220205-0001 05/02/2022 EP20220205-0001 2022020500001 ARNOLD TAMBA 401,402.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
24 RD20220205-0002 05/02/2022 EP20220205-0002 2022020500003 CHRISTIANO P TAMBUNAN 1,850.0

KAPLET
25 RD20220206-0005 06/02/2022 EP20220206-0006 2022020600009 NUR AFIKA 13,190.0

KAPLET
R/ BETAHISTINE 6 MG TAB 6.00 TAB 1,435.00 8,610.00 1 0
26 RD20220206-0006 06/02/2022 EP20220206-0007 2022020600010 ISMAIL 36,788.0

DROP
27 RD20220206-0007 06/02/2022 EP20220206-0008 2022020600011 AULIA RAHMA DANI 18,420.0
TAMBUNAN
R/ ASAM TRANEXAMAT 500 MG 6.00 TAB 2,475.00 14,850.00 1 0

TAB
TAB
28 RD20220206-0008 06/02/2022 EP20220206-0009 2022020600014 WITA SUKMA 140,170.0
29 RD20220206-0009 06/02/2022 EP20220206-0012 2022020600016 YOGI ALEXSANDER 21,493.0

PARDAMEAN PAKPAHAN

KAPLET
30 RD20220206-0010 06/02/2022 EP20220206-0011 2022020600017 TAMARA GERALDIN AGUSTINA 4,580.0

KAPLET
PAKPAHAN
R/ BENANG BRILON 4/0 CUTTING 1.00 PCS 60,500.00 60,500.00 0 1

PAKPAHAN

TAB

KAPLET
33 RD20220206-0013 06/02/2022 EP20220206-0013 2022020600021 PITRA PRATAMA GURUSINGA 20,500.0

R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
34 RD20220208-0003 08/02/2022 EP20220208-0003 2022020800005 YUDISTIRA 131,014.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ CALCIUM LACTATE 500 MG 10.00 TAB 303.00 3,030.00 1 0

TABLET
35 RD20220208-0005 08/02/2022 EP20220208-0005 2022020800010 ROLAN TOGU PARASIAN 158,978.0
36 RD20220208-0006 08/02/2022 EP20220208-0006 2022020800011 MAYANG RISTALENTA 267,290.0

HARIANJA
37 RD20220209-0012 09/02/2022 EP20220209-0011 2022020900020 SHANIA ALI AGATHA 323,438.0

(OOT)
38 RD20220209-0014 09/02/2022 EP20220209-0013 2022020900026 ANGELICA DEBORA 234,432.0

SIMANJUTAK
39 RD20220209-0015 09/02/2022 EP20220209-0014 2022020900028 BONIFASIUS SIHOTANG 117,153.0


(OOT)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
41 RD20220210-0015 10/02/2022 EP20220210-0015 2022021000024 JUANDA PANGARIBUAN 208,292.0
42 RD20220210-0018 10/02/2022 EP20220210-0017 2022021000029 DIDIT SUSANTO 271,076.0

(PREKURSOR)
43 RD20220210-0019 10/02/2022 EP20220210-0018 2022021000031 PUTRI MARINA SINAGA 28,461.0

(PREKURSOR)
44 RD20220210-0020 10/02/2022 EP20220210-0020 2022021000032 NOVIA LISTINA RAHAYU 41,368.0

KAPLET
DROP
45 RD20220210-0021 10/02/2022 EP20220210-0021 2022021000036 NOFRIMA DAKESMI 243,504.0

(PREKURSOR)
46 RD20220210-0022 10/02/2022 EP20220210-0022 2022021000034 ERWIN SITORUS 217,405.0
47 RD20220210-0023 10/02/2022 EP20220210-0019 2022021000035 YOHANES BAPTISTA SALLE 127,194.0

LADO PURAB

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ OTILON EAR DROP 1.00 FLS 53,006.00 53,006.00 0 1
R/ AMBROXOL 30 MG TAB 3.00 TAB 1.00 160.00 40,500.00 1 0
TREMENZA TABLET 20.00 TAB 2,001.00 0.00 0 1

(PREKURSOR)
48 RD20220210-0024 10/02/2022 EP20220210-0023 2022021000037 RUDI YANTO 119,122.0
49 RD20220210-0025 10/02/2022 EP20220210-0024 2022021000038 TETTI ARIANI BUTAR-BUTAR 1,850.0

KAPLET
50 RD20220210-0026 10/02/2022 EP20220210-0025 2022021000039 BERSIUS SITANGGANG 13,710.0

KAPLET
TAB
51 RD20220211-0002 11/02/2022 EP20220211-0002 2022021100002 MAHISA RHANI 164,082.0
R/ EPEXOL TAB 10.00 TAB 1,141.00 11,410.00 0 1
52 RD20220211-0015 11/02/2022 EP20220211-0016 2022021100035 JONI ARESKI 32,489.0
R/ CENDO LYTEERS 0,5 ML 1.00 FLS 5,525.00 5,525.00 0 1

MINIDOSE
TAB
53 RD20220211-0016 11/02/2022 EP20220211-0015 2022021100036 CIHTRA AGUSTINA GULTOM 153,315.0
54 RD20220211-0017 11/02/2022 EP20220211-0017 2022021100037 NAUFAL ZAKY RAMADHAN 213,186.0

R/ SANMOL F SYR 60ML 1.00 BTL 36,186.00 36,186.00 0 1
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ L BIO SACHET 5.00 SACH 9,800.00 49,000.00 0 1
55 RD20220211-0018 11/02/2022 EP20220211-0018 2022021100038 ELVIRA OKTAVIANI 393,220.0
R/ VENOSMIL GEL 1.00 TUBE 224,000.00 224,000.00 0 1
56 RD20220211-0019 11/02/2022 EP20220211-0019 2022021100039 LISNA SARTIKA 210,032.0
57 RD20220211-0020 11/02/2022 EP20220211-0020 2022021100041 NIKE PEBRINA 196,272.0
58 RD20220211-0021 11/02/2022 EP20220211-0021 2022021100043 MUHAMMAD ABIDZAR 89,773.0

ALGIFARI
R/ KERTAS PERKAMEN BERLOGO 9.00 LBR 100.00 900.00 0 1
R/ APIALYS 100 ML SYR 1.00 BTL 45,000.00 45,000.00 0 1
R/ CEFIXIME 100 MG CAP 5.00 CAP 1.00 3,233.00 43,873.00 1 0
INBUMIN TAB 250 MG 3.00 TAB 8,556.00 0.00 0 1
SANMOL 500 MG TABLET 5.00 TAB 408.00 0.00 0 1
59 RD20220211-0022 11/02/2022 EP20220211-0022 2022021100044 SHERINA SYAHPUTRI BR 278,182.0

GINTING
60 RD20220211-0023 11/02/2022 EP20220211-0023 2022021100045 DIDIT ICHWAN 176,932.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
61 RD20220211-0024 11/02/2022 EP20220211-0024 2022021100046 RUTINA SORMIN 284,178.0
62 RD20220211-0025 11/02/2022 EP20220211-0025 2022021100047 YAHYA SYAPUTRA 148,150.0
R/ BUFECT FORTE SYR 1.00 FLS 27,500.00 27,500.00 0 1

MINIDOSE
R/ CENDO FENICOL 1 % SALEP 1.00 FLS 39,500.00 39,500.00 0 0
MATA
63 RD20220211-0026 11/02/2022 EP20220211-0026 2022021100048 DAFFA MUARIF 234,432.0
64 RD20220211-0027 11/02/2022 EP20220211-0027 2022021100050 JHON RENALDO MANURUNG 58,438.0

1GR/100 ML
65 RD20220212-0006 12/02/2022 EP20220212-0007 2022021200012 PERA AGNESCIA 174,232.0

(OOT)
66 RD20220212-0007 12/02/2022 EP20220212-0008 2022021200013 DEDY KOKO ARJUNA 10,100.0

SITUMORANG

KAPLET
67 RD20220212-0008 12/02/2022 EP20220212-0009 2022021200014 NELLY RYANTY PAKPAHAN 104,740.0
68 RD20220212-0009 12/02/2022 EP20220212-0010 2022021200015 APRIANI 221,470.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(OOT)
69 RD20220212-0010 12/02/2022 EP20220212-0011 2022021200016 AFDHAL HABIB SIREGAR 168,296.0
70 RD20220212-0011 12/02/2022 EP20220212-0013 2022021200018 CATHERINE BONITA SIREGAR 194,440.0
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1
71 RD20220212-0012 12/02/2022 EP20220212-0014 2022021200019 SEJAHTERA 23,650.0
72 RD20220212-0014 12/02/2022 EP20220212-0015 2022021200022 SARILAN HARAHAP 35,733.0
R/ BETAHISTINE 6 MG TAB 6.00 TAB 1,435.00 8,610.00 1 0

KAPLET

(BPJS)
74 RD20220213-0014 13/02/2022 EP20220213-0014 2022021300026 NAIFA CAHYA DEWI 56,320.0
R/ SCABIMITE 10 GR CREAM 1.00 TUBE 56,320.00 56,320.00 0 1
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
76 RD20220213-0017 13/02/2022 EP20220213-0016 2022021300037 ASIMA FLORENTINA MANIK 23,486.0

R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
77 RD20220213-0018 13/02/2022 EP20220213-0016 2022021300038 ASIMA FLORENTINA MANIK 10,626.0
79 RD20220216-0002 16/02/2022 EP20220216-0002 2022021600006 RINA NATALIA SITORUS 101,036.0

(PREKURSOR)
(OOT)
80 RD20220216-0003 16/02/2022 EP20220216-0004 2022021600007 MARIA ANTONIA 92,430.0
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
81 RD20220216-0004 16/02/2022 EP20220216-0005 2022021600009 WANRA HUTAPEA 58,438.0

1GR/100 ML
82 RD20220216-0005 16/02/2022 EP20220216-0003 2022021600014 SRI WULANDARI 65,220.0

(PREKURSOR)
83 RD20220216-0006 16/02/2022 EP20220216-0004 2022021600015 MARIA ANTONIA 132,012.0
84 RD20220216-0007 16/02/2022 EP20220216-0006 2022021600016 YESLINDA BR KARO 68,874.0

(PREKURSOR)

85 RD20220216-0008 16/02/2022 EP20220216-0007 2022021600017 ZURANISA AGUSTINI 148,122.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
86 RD20220216-0010 16/02/2022 EP20220216-0008 2022021600020 LAMAIDI 119,122.0
87 RD20220216-0011 16/02/2022 EP20220216-0011 2022021600021 ALIDE TAMBA 70,350.0

(OOT)
(PREKURSOR)
88 RD20220216-0012 16/02/2022 EP20220216-0012 2022021600022 MARLAN MANALU 101,000.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
89 RD20220216-0013 16/02/2022 EP20220216-0009 2022021600023 WILDA GABRIELSA SIREGAR 129,212.0
90 RD20220216-0014 16/02/2022 EP20220216-0013 2022021600026 LUSIYANTI SIHOMBING 56,496.0
R/ EPEXOL TAB 10.00 TAB 1,141.00 11,410.00 0 1

(PREKURSOR)
91 RD20220216-0015 16/02/2022 EP20220216-0015 2022021600029 BILQIS ULFAIRA 270,878.0

(BPJS)

(OOT)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ SUNGKUP NEBULIZER ANAK 1.00 PCS 50,150.00 50,150.00 0 1
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1
92 RD20220216-0016 16/02/2022 EP20220216-0014 2022021600028 MECHTILDIS NOVELIA AURA 20,500.0

LADDY
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
93 RD20220216-0017 16/02/2022 EP20220216-0016 2022021600032 JUANDA RIZKI 295,148.0

(PREKURSOR)
94 RD20220216-0018 16/02/2022 EP20220216-0017 2022021600033 XAVIER ALI IMRAN 9,269.0

(BPJS)
95 RD20220216-0019 16/02/2022 EP20220216-0018 2022021600034 ROMARTA HALOHO 72,978.0
R/ MEFINAL 10.00 KAPLET 2,019.00 20,190.00 0 1

500 MG
R/ EPEXOL
KAPLET SYRUP 1.00 BTL 23,788.00 23,788.00 0 1
96 RD20220216-0020 16/02/2022 EP20220216-0019 2022021600035 AHMAD YANI 206,470.0
97 RD20220217-0008 17/02/2022 EP20220217-0010 2022021700020 HENDRI RUDIANTO 155,452.0
98 RD20220217-0009 17/02/2022 EP20220217-0011 2022021700025 SURIANSYAH 88,530.0

(OOT)
99 RD20220217-0010 17/02/2022 EP20220217-0014 2022021700026 FANIA AQILA BR SINUKABAN 219,186.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1
R/ SANMOL F SYR 60ML 1.00 BTL 36,186.00 36,186.00 0 1

(OOT)
101 RD20220217-0012 17/02/2022 EP20220217-0012 2022021700030 IKA BUDIYATNI 70,950.0
R/ EPEXOL TAB 10.00 TAB 1,141.00 11,410.00 0 1
102 RD20220217-0013 17/02/2022 EP20220217-0016 2022021700031 ELKANA 262,776.0
103 RD20220217-0014 17/02/2022 EP20220217-0015 2022021700034 LUSIA DAMAI YANA MURNI 129,962.0

(OOT)
104 RD20220217-0015 17/02/2022 EP20220217-0019 2022021700035 AUDINA 161,892.0
105 RD20220217-0016 17/02/2022 EP20220217-0017 2022021700036 MARIA ANA LIPAT 60,000.0

1GR/100 ML
106 RD20220217-0017 17/02/2022 EP20220217-0020 2022021700037 MUHAMMAD HANAFI 187,398.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
108 RD20220217-0019 17/02/2022 EP20220217-0021 2022021700043 SARLES SINAGA 185,478.0
109 RD20220217-0020 17/02/2022 EP20220217-0022 2022021700045 TARULI SINAGA 37,746.0

(PREKURSOR)
110 RD20220217-0021 17/02/2022 EP20220217-0023 2022021700049 CAROLINA SIMANJUNTAK 271,128.0

(PREKURSOR)
111 RD20220217-0022 17/02/2022 EP20220217-0008 2022021700051 FRENTRY SIHOMBING 24,360.0
112 RD20220217-0023 17/02/2022 EP20220217-0024 2022021700054 ANA MARIANA 24,520.0
R/ SET MAKRO 1.00 PCS 13,720.00 13,720.00 0 1
113 RD20220217-0024 17/02/2022 EP20220217-0025 2022021700058 ZHAO ZHANGLANG 61,580.0
114 RD20220217-0025 17/02/2022 EP20220217-0026 2022021700059 HERDALINA MANURUNG 113,972.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
115 RD20220217-0026 17/02/2022 EP20220217-0026 2022021700061 HERDALINA MANURUNG 159,102.0
R/ THROMBOPHOB GEL 1.00 TUBE 68,063.00 68,063.00 0 1

(OOT)
117 RD20220217-0028 17/02/2022 EP20220217-0028 2022021700063 GABARIELLA SABA TINI M 191,260.0
118 RD20220217-0029 17/02/2022 EP20220217-0024 2022021700064 ANA MARIANA 24,360.0
119 RD20220218-0022 18/02/2022 EP20220218-0016 2022021800043 YUNI ANGGELA GINTING 250,604.0
120 RD20220218-0023 18/02/2022 EP20220218-0017 2022021800044 ELFIRITA SIMATUPANG 63,527.0
121 RD20220218-0024 18/02/2022 EP20220218-0020 2022021800045 NICHOLAS SERGIO 17,600.0

SITUMORANG
122 RD20220218-0025 18/02/2022 EP20220218-0020 2022021800046 NICHOLAS SERGIO 38,100.0

SITUMORANG

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
123 RD20220218-0026 18/02/2022 EP20220218-0018 2022021800047 RIKI HAMDANI 119,122.0
124 RD20220218-0027 18/02/2022 EP20220218-0019 2022021800048 IRMAYA SARI 141,362.0

(PREKURSOR)
125 RD20220218-0028 18/02/2022 EP20220218-0021 2022021800049 YESAYA TARIGAN 228,716.0
126 RD20220218-0029 18/02/2022 EP20220218-0022 2022021800050 VENNY MALINDRA 104,580.0
127 RD20220218-0030 18/02/2022 EP20220218-0024 2022021800051 OKTARIANI 218,282.0

(PREKURSOR)
128 RD20220218-0031 18/02/2022 EP20220218-0025 2022021800052 TOMMY ROLIS 152,103.0
129 RD20220218-0032 18/02/2022 EP20220218-0026 2022021800055 LATIFA RAMDONA 125,768.0

KAPLET

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
130 RD20220218-0033 18/02/2022 EP20220218-0027 2022021800056 SEPRIO 263,112.0
131 RD20220218-0034 18/02/2022 EP20220218-0028 2022021800057 ALIZKA ILLONA GULTOM 109,288.0
R/ L BIO SACHET 3.00 SACH 9,800.00 29,400.00 0 1
132 RD20220218-0035 18/02/2022 EP20220218-0029 2022021800058 ABEDNEGO SIMAGUNSONG 280,124.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1

(PREKURSOR)
R/ SIDIADRYL 150MG/15ML INJ 1.00 CC 1,375.00 1,375.00 0 1
135 RD20220218-0039 18/02/2022 EP20220218-0033 2022021800064 DEWI FEBRIANTI 110,803.0
R/ THROMBOPHOB GEL 1.00 TUBE 68,063.00 68,063.00 0 1
136 RD20220218-0040 18/02/2022 EP20220218-0034 2022021800065 SYAFRI ELDI 209,614.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
137 RD20220219-0018 19/02/2022 EP20220219-0015 2022021900035 WANSI SITUMORANG 60,000.0

1GR/100 ML
138 RD20220219-0019 19/02/2022 EP20220219-0014 2022021900039 CINTA JUMAGAR SIANIAPAR 37,780.0

(OOT)
139 RD20220219-0020 19/02/2022 EP20220219-0016 2022021900040 183,485.0
140 RD20220219-0021 19/02/2022 EP20220219-0017 2022021900041 ZAINUDDIN MANALU 360,780.0
141 RD20220219-0022 19/02/2022 EP20220219-0018 2022021900043 MALUL ANSARI BATUBARA 248,638.0
142 RD20220219-0023 19/02/2022 EP20220219-0019 2022021900044 SRI PUTRI ANANDA 92,430.0
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
143 RD20220219-0024 19/02/2022 EP20220219-0020 2022021900046 ENDAH 190,122.0

DWI
RIYANI

144 RD20220219-0025 19/02/2022 EP20220219-0019 2022021900047 SRI PUTRI ANANDA 190,122.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
145 RD20220221-0016 21/02/2022 EP20220221-0017 2022022100042 WIMBI TRIANDA 111,052.0

(OOT)
146 RD20220221-0017 21/02/2022 EP20220221-0018 2022022100043 DIKI PRATAMA PUTRA 23,978.0

KAPLET
147 RD20220221-0018 21/02/2022 EP20220221-0019 2022022100045 DELFINORA PASARIBU 316,004.0
148 RD20220221-0019 21/02/2022 EP20220221-0021 2022022100047 ROIS IGREYA BARUS 21,493.0

KAPLET
149 RD20220221-0020 21/02/2022 EP20220221-0020 2022022100048 DINI OKTAVIA GULTOM 12,908.0
R/ AMOXICILLIN 500 MG KAPLET 4.00 KAPLET 1.00 482.00 6,068.00 1 0
AMBROXOL 30 MG TAB 4.00 TAB 285.00 0.00 1 0
CETIRIZINE 10 MG TAB 2.00 TAB 1,000.00 0.00 1 0

151 RD20220221-0022 21/02/2022 EP20220221-0023 2022022100050 FAYTRIMA LUMBANGAOL 220,682.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ FARBION INJ 1.00 AMP 10,000.00 10,000.00 0 1
154 RD20220221-0025 21/02/2022 EP20220221-0027 2022022100057 YULIANA TARIHORAN 113,664.0
155 RD20220221-0026 21/02/2022 EP20220221-0026 2022022100058 RAIHAN DHEFAL VAN HALEN 215,982.0
156 RD20220221-0027 21/02/2022 EP20220221-0024 2022022100059 AZKA NAUFAL AL MUSTOFA 110,423.0

(BPJS)
(BPJS)
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

RECTAL TUBE
157 RD20220221-0028
(PSIKOTROPIKA) 21/02/2022 EP20220221-0024 2022022100060 AZKA NAUFAL AL MUSTOFA 52,953.0
R/ SUNGKUP OKSIGEN ANAK 1.00 PCS 52,953.00 52,953.00 0 1
158 RD20220221-0029 21/02/2022 EP20220221-0028 2022022100061 ARIS KASNUR 111,360.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
159 RD20220221-0030 21/02/2022 EP20220221-0029 2022022100070 FLOWERIDA SITANGGANG 259,457.0
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1
160 RD20220221-0032 21/02/2022 EP20220221-0024 2022022100074 AZKA NAUFAL AL MUSTOFA 50,150.0
161 RD20220222-0017 22/02/2022 EP20220222-0018 2022022200026 MONIKA TAMBA 134,570.0
R/ GITAS PLUS TAB 6.00 TAB 8,388.00 50,328.00 0 1
163 RD20220222-0019 22/02/2022 EP20220222-0020 2022022200028 SASTRINDU MAWANTI 300,482.0

BR.MANIK
R/ GITAS PLUS TAB 10.00 TAB 8,388.00 83,880.00 0 1
164 RD20220222-0020 22/02/2022 EP20220222-0021 2022022200030 ALFIY FADHILILLAH 130,270.0
165 RD20220222-0021 22/02/2022 EP20220222-0023 2022022200031 RAHMAT PRATAMA 3,880.0

KAPLET
166 RD20220222-0022 22/02/2022 EP20220222-0022 2022022200032 MENTERIA SIHOTANG 112,746.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

(OOT)
167 RD20220222-0023 22/02/2022 EP20220222-0024 2022022200034 MELVA N OMPUSUNGGU 108,720.0

(OOT)
168 RD20220222-0024 22/02/2022 EP20220222-0025 2022022200035 ALBERTUS REFILINO RICOAC 2,750.0
R/ SIDIADRYL 150MG/15ML INJ 2.00 CC 1,375.00 2,750.00 0 1
169 RD20220222-0025 22/02/2022 EP20220222-0025 2022022200036 ALBERTUS REFILINO RICOAC 206,302.0
170 RD20220222-0026 22/02/2022 EP20220222-0026 2022022200037 DENTO 66,758.0

KAPLET
171 RD20220222-0027 22/02/2022 EP20220222-0026 2022022200038 DENTO 5,610.0
R/ BISTURI NO. 22 1.00 PCS 5,610.00 5,610.00 0 1
172 RD20220222-0028 22/02/2022 EP20220222-0027 2022022200039 27,500.0
R/ BUFECT FORTE SYR 1.00 FLS 27,500.00 27,500.00 0 1
173 RD20220223-0013 23/02/2022 EP20220223-0012 2022022300024 GRACE OMPUSUNGGU 36,835.0

(OOT)
KAPLET
174 RD20220223-0014 23/02/2022 EP20220223-0013 2022022300025 RANA AFRILIA PUTRI 177,512.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
175 RD20220223-0015 23/02/2022 EP20220223-0014 2022022300029 FIRDO HAPE PURBA 18,940.0

CAPSUL
176 RD20220223-0016 23/02/2022 EP20220223-0015 2022022300030 SANDRA RIZALDI 115,000.0
177 RD20220223-0017 23/02/2022 EP20220223-0016 2022022300031 ELVINA SARI BANGUN 11,733.0

(BPJS)
178 RD20220225-0002 25/02/2022 EP20220225-0003 2022022500008 DEWARNI PANGGABEAN 88,530.0

(OOT)
179 RD20220225-0003 25/02/2022 EP20220225-0006 2022022500010 FARID ASNGARI 41,486.0

KAPLET
181 RD20220225-0005 25/02/2022 EP20220225-0008 2022022500013 DEASY HARYANI 268,782.0
182 RD20220225-0006 25/02/2022 EP20220225-0010 2022022500016 RUDI ARDIAN 264,450.0

183 RD20220225-0007 25/02/2022 EP20220225-0009 2022022500017 SEFRINA SUSANTI SINAGA 122,740.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
184 RD20220225-0008 25/02/2022 EP20220225-0011 2022022500018 APUL MARPAUNG 11,050.0

MINIDOSE
185 RD20220225-0009 25/02/2022 EP20220225-0013 2022022500019 RENA MEYLANI 136,978.0

DROP
186 RD20220225-0010 25/02/2022 EP20220225-0014 2022022500020 LIDIA BR SIANTURI 5,450.0
187 RD20220225-0011 25/02/2022 EP20220225-0015 2022022500024 FITRI JULIYANI 187,810.0

(PREKURSOR)
188 RD20220225-0013 25/02/2022 EP20220225-0019 2022022500030 HIDAYAH PUTRI ANDANI 194,894.0
R/ FREGO 5 MG TAB 3.00 TAB 8,448.00 25,344.00 0 0
189 RD20220225-0016 25/02/2022 EP20220225-0021 2022022500036 FEDERICO PRATAMA 16,088.0

SITUMORANG
190 RD20220225-0017 25/02/2022 EP20220225-0020 2022022500037 IDARIA AGNES SINAGA 4,680.0
191 RD20220226-0004 26/02/2022 EP20220226-0004 2022022600006 NADILA PUTRI ARANI 274,302.0
R/ KETOROLAC 10 MG TAB 10.00 TAB 3,520.00 35,200.00 1 0

RENGGANIS

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ TREMENZA TABLET 6.00 TAB 2,001.00 ### 0 1

(PREKURSOR)
(OOT)
193 RD20220226-0006 26/02/2022 EP20220226-0005 2022022600008 YOGI FAJRI 252,247.0
R/ KETOROLAC 10 MG TAB 10.00 TAB 3,520.00 35,200.00 1 0
195 RD20220226-0008 26/02/2022 EP20220226-0007 2022022600011 RENGGA 218,248.0

(PREKURSOR)
(OOT)
196 RD20220226-0009 26/02/2022 EP20220226-0008 2022022600014 ABID RAFFASYAH PRANAJA 30,473.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1

(BPJS)
Total Dokter DR. SHINLY MEIVINITA GINTING 24,811,003.0
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. STEVEN, SP.OG
1 RI20220219-0030 19/02/2022 RI20220219-0004 RI20220219-0030 BERLIANA SIREGAR 258,284.0
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

KAPLET
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
(BPJS)
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

KAPLET

KAPLET
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ MEMUCIL 600 MG 1.00 TAB 14,000.00 14,000.00 0 1

EFFERVESCENT
R/ ESOMEPRAZOLE INJ (BPJS) 1.00 VIAL 103,950.00 103,950.00 1 0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ NACL 0.9 % 500 ML INF 3.00 FLS 13,333.00 39,999.00 1 0

KAPLET
R/ RESFAR 25 ML 1.00 FLS 280,192.00 280,192.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

(GAMMEX) NO. 7

CAPSUL
9 RI20220223-0003 23/02/2022 RI20220222-0001 RI20220223-0003 DORLINA NUR HIDAYAH 46,586.0
PANJAITAN
R/ CEFOTAXIME 1 GR INJ 1.00 VIAL 9,355.00 9,355.00 1 0
R/ VIATRIN 0,125 MG TABLET 3.00 TAB 3,575.00 10,725.00 0 0
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1

KAPLET
PANJAITAN
R/ PETHIDIN HCL 50 MG/ML INJ 1.00 AMP 26,300.00 26,300.00 0 0

(NARKOTIKA)
R/ ATROPIN SULFAS INJ 1.00 AMP 3,375.00 3,375.00 1 0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0

500MG/5ML
R/ CEFOTAXIME 1 GR INJ 1.00 VIAL 9,355.00 9,355.00 1 0
R/ RANITIDINE 50MG/2ML INJ 1.00 AMP 8,800.00 8,800.00 1 0
R/ VALISANBE 5 MG/2 ML INJ 1.00 AMP 23,554.00 23,554.00 0 0

(PSIKOTROPIKA)
R/ RL 500 ML INF 1.00 FLS 9,766.00 9,766.00 0 1
R/ METHYLERGOMETRIN MALEAT 2.00 AMP 4,890.00 9,780.00 1 0

INJ (OOT)
R/ SET DARAH 1.00 PCS 7,157.00 7,157.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

PANJAITAN

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

KAPLET

CAPSUL
PANJAITAN

INJ (BPJS)
R/ NACL 0.9 % 500 ML INF 1.00 FLS 13,333.00 13,333.00 1 0

PANJAITAN
R/ BIONEMI CAPSUL 10.00 CAP 2,282.00 22,820.00 0 1
R/ CEFADROXYL 500 MG CAPSUL 10.00 CAP 1,050.00 10,500.00 1 0

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1
R/ DEVIT 1000 IU 3.00 TAB 2,600.00 7,800.00 0 1

CAPSUL
R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

CAPSUL
22 RJ20220207-0007 07/02/2022 OP20220207-0006 2022020700010 HERLINA SUPARTINI 35,750.0
R/ VIATRIN 0,125 MG TABLET 10.00 TAB 3,575.00 35,750.00 0 0
23 RJ20220207-0008 07/02/2022 OP20220207-0013 2022020700012 WITA SUKMA 46,200.0
R/ NORELUT 5 MG TAB 7.00 TAB 6,600.00 46,200.00 0 1
24 RJ20220207-0009 07/02/2022 OP20220207-0015 2022020700014 RUSTINA IRMAYANTI 683,190.0

TAMPUBOLON
R/ HI BONE KAPLET 30.00 KAPLET 4,000.00 120,000.00 0 1
25 RJ20220214-0007 14/02/2022 OP20220214-0006 2022021400008 YELVIDA 167,190.0
26 RJ20220216-0007 16/02/2022 OP20220216-0010 2022021600008 RANI SEVENTINA 683,190.0
R/ HI BONE KAPLET 30.00 KAPLET 4,000.00 120,000.00 0 1
27 RJ20220221-0006 21/02/2022 OP20220221-0013 2022022100006 RENATA NZELINA SITOHANG 167,190.0
Total Dokter DR. STEVEN, SP.OG 3,785,022.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. TIMBUL M. SILITONGA
1 RD20220201-0001 01/02/2022 EP20220201-0001 2022020100001 EKA VALINTINA 14,260.0

KAPLET
R/ NEW DIATAB TABLET 10.00 TAB 696.00 6,960.00 0 1
2 RD20220201-0002 01/02/2022 EP20220201-0001 2022020100002 EKA VALINTINA 63,360.0
3 RD20220202-0001 02/02/2022 EP20220202-0001 2022020200001 GABBRIEL TIO GABE 71,920.0

KAPLET

(OOT)
5 RD20220205-0003 05/02/2022 EP20220205-0003 2022020500006 ADITYA CHANDRA 361,670.0
6 RD20220205-0004 05/02/2022 EP20220205-0004 2022020500008 FARAMITA YOLANDA 245,588.0
7 RD20220206-0001 06/02/2022 EP20220206-0004 2022020600006 MEXI 17,600.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
8 RD20220206-0004 06/02/2022 EP20220206-0005 2022020600008 BERLAN .L.PASARIBU 24,050.0
9 RD20220207-0001 07/02/2022 EP20220207-0002 2022020700001 JODI CAVIN TANSESE MUNTHE 63,360.0
10 RD20220207-0002 07/02/2022 EP20220207-0002 2022020700002 JODI CAVIN TANSESE MUNTHE 94,570.0
11 RD20220207-0003 07/02/2022 EP20220207-0003 2022020700004 DICKY ARDIANSYAH 85,704.0
12 RD20220207-0004 07/02/2022 EP20220207-0004 2022020700005 CHELVIN RAMADHAN 201,870.0

PRATAMA
R/ ARCAPEC TAB 10.00 TAB 1,512.00 15,120.00 0 1

(OOT)
13 RD20220207-0005 07/02/2022 EP20220207-0005 2022020700006 DERISMANTO MUNTHE 297,460.0
14 RD20220207-0006 07/02/2022 EP20220207-0006 2022020700007 VINA NOVISRAMULYA 62,180.0
15 RD20220207-0007 07/02/2022 EP20220207-0009 2022020700008 RINI ANDRIANI BR SINAGA 55,950.0

(OOT)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
16 RD20220207-0008 07/02/2022 EP20220207-0008 2022020700009 BAYU WIDI SASONGKO ###
17 RD20220207-0009 07/02/2022 EP20220207-0007 2022020700010 NORMAH 4,980.0
R/ SALBUTAMOL 2 MG TAB 10.00 TAB 118.00 1,180.00 1 0
18 RD20220207-0010 07/02/2022 EP20220207-0007 2022020700011 NORMAH 80,690.0

DEWASA
(BPJS)
19 RD20220207-0011 07/02/2022 EP20220207-0011 2022020700012 JHON ANDRYANTO SILAEN 60,030.0

(OOT)

(BPJS)
21 RD20220207-0013 07/02/2022 EP20220207-0013 2022020700019 FATMAWATI 63,360.0

(BPJS)
22 RD20220207-0014 07/02/2022 EP20220207-0013 2022020700020 FATMAWATI 32,975.0
R/ URINE BAG 1.00 PCS 8,000.00 8,000.00 0 1
23 RD20220207-0015 07/02/2022 EP20220207-0013 2022020700021 FATMAWATI 96,910.0
R/ NALD 26 (ONEMED) 1.00 PCS 660.00 660.00 0 0
24 RD20220207-0016 07/02/2022 EP20220207-0014 2022020700022 NURMA PARHUSIP 16,950.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
25 RD20220208-0007 08/02/2022 EP20220208-0007 2022020800012 LIDWINA NOVENA SARODJA 75,460.0
26 RD20220208-0008 08/02/2022 EP20220208-0008 2022020800013 WAHID HUSIN 117,698.0
27 RD20220208-0009 08/02/2022 EP20220208-0009 2022020800014 DARMAWATI 11,500.0
28 RD20220208-0010 08/02/2022 EP20220208-0009 2022020800015 DARMAWATI 63,360.0

(BPJS)
29 RD20220208-0011 08/02/2022 EP20220208-0010 2022020800016 IBROHIM 206,470.0
30 RD20220208-0012 08/02/2022 EP20220208-0011 2022020800018 RATU AYU DIRGANTARA 216,420.0

(OOT)
31 RD20220208-0013 08/02/2022 EP20220208-0012 2022020800019 RAHMA PATIKAWA 204,410.0
32 RD20220208-0014 08/02/2022 EP20220208-0013 2022020800020 YOHANES HANRI PORTARE 6,280.0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
33 RD20220208-0015 08/02/2022 EP20220208-0014 2022020800021 NATALINA TAMBUNAN 12.0
34 RD20220208-0016 08/02/2022 EP20220208-0015 2022020800024 CHRISTOPER HP SITANGGANG 63,360.0

(BPJS)
35 RD20220210-0001 10/02/2022 EP20220210-0001 2022021000001 VIOLA DWI AMELIZA 98,250.0
36 RD20220211-0001 11/02/2022 EP20220211-0001 2022021100001 FITRI NURAINI 272,540.0
37 RD20220211-0028 11/02/2022 EP20220211-0028 2022021100052 HELDERIKA SILITONGA 240,470.0

(PREKURSOR)
Total Dokter DR. TIMBUL M. SILITONGA 4,160,835.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
Dokter : DR. YURI SP.A
1 RI20220201-0001 01/02/2022 RI20220130-0002 RI20220201-0001 RAFAEL AGUSTIAN DUHA 82,000.0
R/ D5 +1/2 NS 500 ML (WIDA) 4.00 FLS 20,500.00 82,000.00 0 1
2 RI20220201-0002 01/02/2022 RI20220129-0003 RI20220201-0002 WAI RUI CHIN 41,000.0
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
3 RI20220201-0003 01/02/2022 RI20220130-0003 RI20220201-0003 RIRIN APRILLYA 348,475.0
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
4 RI20220201-0004 01/02/2022 RI20220130-0001 RI20220201-0004 HEZRON SITOMPUL 69,015.0
R/ D5 + 1/4 NS 500 ML ( WIDA ) 3.00 FLS 23,005.00 69,015.00 0 1

INJ (BPJS)
R/ PICYN 750 MG INJ (BPJS) 2.00 VIAL 75,000.00 150,000.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
6 RI20220201-0007 01/02/2022 RI20220131-0001 RI20220201-0007 REYNALDI SINURAT 34,023.0

KAPLET
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1


INJ (BPJS)
8 RI20220201-0010 01/02/2022 RI20220126-0001 RI20220201-0010 RANEL ELVANO PANGARIBUAN 117,614.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
R/ INTERLAC SACHET 6.00 SACH 10,000.00 60,000.00 0 1
9 RI20220201-0011 01/02/2022 RI20220201-0001 RI20220201-0011 TEGAR TRI ATMAJA 20,625.0
R/ CETIRIZINE SIRUP 1.00 BTL 20,625.00 20,625.00 1 0
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
13 RI20220202-0008 02/02/2022 RI20220201-0002 RI20220202-0008 SITI NURLIYA 29,298.0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

INJ (BPJS)
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
16 RI20220202-0015 02/02/2022 RI20220130-0003 RI20220202-0015 RIRIN APRILLYA 286,645.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
17 RI20220202-0016 02/02/2022 RI20220130-0001 RI20220202-0016 HEZRON SITOMPUL 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
19 RI20220202-0030 02/02/2022 RI20220202-0003 RI20220202-0030 CHIARA GRACE. H.S 75,120.0
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

INJ (BPJS)
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

(PSIKOTROPIKA)

R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

INJ (BPJS)
28 RI20220203-0027 03/02/2022 RI20220203-0001 RI20220203-0027 GRACELESA AMORA SITORUS 235,123.0
R/ D5 + 1/4 NS 500 ML ( WIDA ) 3.00 FLS 23,005.00 69,015.00 0 1

R/ D5 + 1/4 NS 500 ML ( WIDA ) 2.00 FLS 23,005.00 46,010.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

INJ (BPJS)
(BPJS)
32 RI20220204-0009 04/02/2022 RI20220130-0002 RI20220204-0009 RAFAEL AGUSTIAN DUHA ###
R/ FLUCONAZOLE 150 MG TAB 2.00 TAB 1.00 29,700.00 60,400.00 1 0


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1

KAPLET
36 RI20220204-0023 04/02/2022 RI20220204-0003 RI20220204-0023 KAILA PEPAYOSA HUTASOIT 259,240.0
R/ D5 + 1/4 NS 500 ML ( WIDA ) 3.00 FLS 23,005.00 69,015.00 0 1
R/ SANMOL 15 ML DROP 1.00 FLS 22,106.00 22,106.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

INJ (BPJS)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ D5 + 1/4 NS 500 ML ( WIDA ) 2.00 FLS 23,005.00 46,010.00 0 1

KAPLET
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1

INJ (BPJS)
R/ D5 + 1/4 NS 500 ML ( WIDA ) 2.00 FLS 23,005.00 46,010.00 0 1
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
53 RI20220206-0022 06/02/2022 RI20220206-0004 RI20220206-0022 PITRA PRATAMA GURUSINGA 63,015.0
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ ERYSANBE 60 ML SYR 1.00 FLS 28,875.00 28,875.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
60 RI20220211-0014 11/02/2022 RI20220211-0003 RI20220211-0014 MUHAMMAD HASAN 804,199.0

HERWANTO
R/ RANTIN INJ 50 MG/ 2ML 2.00 AMP 20,000.00 40,000.00 0 1
R/ SANMOL INFUS 2.00 FLS 86,029.00 172,058.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ BIOCEF 1 GR INJ 2.00 VIAL 197,120.00 394,240.00 0 1
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

HERWANTO
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
62 RI20220211-0022 11/02/2022 RI20220211-0004 RI20220211-0022 NAURA SYAKIRA ARSYIDINATA 74,318.0
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
63 RI20220211-0023 11/02/2022 RI20220211-0001 RI20220211-0023 KRISTIAN KERANS 320,881.0

(PSIKOTROPIKA)
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

INJ (BPJS)
Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
64 RI20220211-0024 11/02/2022 RI20220211-0006 RI20220211-0024 KATARINA FITRIA 41,337.0
R/ RL 500 ML INF 3.00 FLS 9,766.00 29,298.00 0 1

INJ (BPJS)
65 RI20220211-0026 11/02/2022 RI20220211-0006 RI20220211-0026 KATARINA FITRIA 555.0

KAPLET
66 RI20220211-0033 11/02/2022 RI20220211-0007 RI20220211-0033 JHON RENALDO MANURUNG 804,053.0
R/ SANMOL INFUS 3.00 FLS 86,029.00 258,087.00 0 1
R/ ELKANA CL SYR 1.00 FLS 70,331.00 70,331.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

INJ (BPJS)
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

HERWANTO

R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ RANTIN INJ 50 MG/ 2ML 1.00 AMP 20,000.00 20,000.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

HERWANTO
R/ NALD 18 ( TERUMO) 1.00 PCS 4,568.00 4,568.00 0 1
72 RI20220212-0011 12/02/2022 RI20220211-0001 RI20220212-0011 KRISTIAN KERANS 156,888.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
74 RI20220212-0018 12/02/2022 RI20220212-0001 RI20220212-0018 MUHAMMAD HUSEIN 22,106.0

HERWANTO

HERWANTO
76 RI20220212-0022 12/02/2022 RI20220211-0003 RI20220212-0022 MUHAMMAD HASAN 4.0

HERWANTO
R/ MASKER KN 95 4.00 PCS 1.00 4.00 0 1

HERWANTO

HERWANTO


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

HERWANTO
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

INJ (BPJS)
R/ RL 500 ML INF 2.00 FLS 9,766.00 19,532.00 0 1
85 RI20220213-0014 13/02/2022 RI20220212-0003 RI20220213-0014 AURELIA TASHA TAMPUBOLON 6,006.0

HERWANTO

HERWANTO
R/ MOMETASON CREAM 10 GR 1.00 TUBE 20,000.00 20,000.00 1 0
88 RI20220213-0019 13/02/2022 RI20220213-0001 RI20220213-0019 MARIA GISELA NONA 356,987.0
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

1GR/100 ML

HERWANTO

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

HERWANTO
91 RI202202 14/02/2022 RI20220211-0004 RI20220214-0004 NAURA SYAKIRA ARSYIDINATA 41,000.0

14-0004
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

HERWANTO
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

INJ (BPJS)
94 RI20220214-0015 14/02/2022 RI20220212-0003 RI20220214-0015 AURELIA TASHA TAMPUBOLON 156,888.0
R/ ELKANA SYR 1.00 FLS 28,875.00 28,875.00 0 1
95 RI20220214-0016 14/02/2022 RI20220211-0006 RI20220214-0016 KATARINA FITRIA 555.0

KAPLET
R/ VIVENA INJ 1.00 VIAL 73,000.00 73,000.00 0 1
R/ TROMBUFIT SACHET 10.00 SACH 7,333.00 73,330.00 0 1

HERWANTO

HERWANTO


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

KAPLET
R/ CEFIXIME DRY 30 ML SYR 1.00 BTL 40,838.00 40,838.00 1 0
103 RI20220216-0021 16/02/2022 RI20220216-0002 RI20220216-0021 MECHTILDIS NOVELIA AURA 286,500.0

LADDY
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

LADDY
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

LADDY
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1

LADDY
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
107 RI20220218-0020 18/02/2022 RI20220216-0002 RI20220218-0020 MECHTILDIS NOVELIA AURA 861.0

LADDY
R/ NALD 18 (ONEMED) 1.00 PCS 861.00 861.00 1 0
108 RI20220218-0031 18/02/2022 RI20220218-0003 RI20220218-0031 NICHOLAS SERGIO 117,606.0

SITUMORANG

R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

LADDY
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

SITUMORANG
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1
R/ D5 + 1/4 NS 500 ML ( WIDA ) 2.00 FLS 23,005.00 46,010.00 0 1
111 RI20220219-0024 19/02/2022 RI20220219-0002 RI20220219-0024 SHYALOMI LETHISIA KHEREN 307,330.0

MANURUNG
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1
R/ AQUADES 25 ML 50.00 CC 356.00 17,800.00 0 1

MANURUNG

LADDY
R/ TROMBUFIT SACHET 1.00 SACH 7,333.00 7,333.00 0 1

LADDY

SITUMORANG

MANURUNG

LADDY
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

SITUMORANG
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

MANURUNG
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

SITUMORANG

SITUMORANG

SITUMORANG

MANURUNG
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
124 RI20220220-0046 20/02/2022 RI20220220-0002 RI20220220-0046 WALID MARZUQI SARUMPAET 202,000.0
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

MANURUNG
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

LADDY


Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula

SITUMORANG

LADDY
R/ AQUADES 25 ML 25.00 CC 356.00 8,900.00 0 1

LADDY
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
133 RI20220222-0001 21/02/2022 RI20220221-0002 RI20220222-0001 AZKA NAUFAL AL MUSTOFA 71,486.0
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1

NEEDLE) ONEMED

INJ (BPJS)
R/ ELEKTRODY EKG ANAK 5.00 PCS 13,066.00 65,330.00 0 1

SKINTACT
RECTAL TUBE
R/ STESOLID 10 MG/2ML
(PSIKOTROPIKA) 1.00 AMP 16,108.00 16,108.00 0 0
R/ NORAGES INJEKSI 500MG/2ML 1.00 AMP 11,481.00 11,481.00 0 1

INJ (BPJS)

MANURUNG
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1

INJ (BPJS)

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ D5 +1/2 NS 500 ML (WIDA) 1.00 FLS 20,500.00 20,500.00 0 1
141 RI20220226-0018 26/02/2022 RI20220226-0001 RI20220226-0018 ABID RAFFASYAH PRANAJA 215,444.0
R/ NALD 18 ( TERUMO) 2.00 PCS 4,568.00 9,136.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
145 RI20220227-0015 27/02/2022 RI20220227-0002 RI20220227-0015 DIAZ JOSHUA SIMAMORA 538,200.0
R/ AQUADES 25 ML 75.00 CC 356.00 26,700.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 3.00 FLS 20,500.00 61,500.00 0 1

INJ (BPJS)
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

INJ (BPJS)
149 RI20220228-0006 28/02/2022 RI20220228-0001 RI20220228-0006 TERESIA AYULINA TIVANY 191,000.0
SIALLAGAN
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1

150 RI20220228-0009 28/02/2022 RI20220228-0002 RI20220228-0009 GRASELLA SESILIA SIMAMORA 41,000.0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
R/ D5 +1/2 NS 500 ML (WIDA) 2.00 FLS 20,500.00 41,000.00 0 1
151 RI20220228-0013 28/02/2022 RI20220228-0001 RI20220228-0013 TERESIA AYULINA TIVANY 1,467.0

SIALLAGAN
R/ NALD 18 (ONEMED) 1.00 PCS 861.00 861.00 1 0
152 RI20220228-0014 28/02/2022 RI20220228-0002 RI20220228-0014 GRASELLA SESILIA SIMAMORA 2,419.0
R/ NALD 23 (ONEMED) 1.00 PCS 1,813.00 1,813.00 0 1
R/ NALD 23 (ONEMED) 1.00 PCS 1,813.00 1,813.00 0 1
154 RJ20220207-0001 07/02/2022 OP20220207-0001 2022020700001 SITI NURLIYA 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
155 RJ20220207-0002 07/02/2022 OP20220207-0002 2022020700002 REYNALDI SINURAT 43,314.0
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
156 RJ20220207-0003 07/02/2022 OP20220207-0003 2022020700003 FADHILLA INAYAH.S 50,150.0
157 RJ20220207-0004 07/02/2022 OP20220207-0003 2022020700004 FADHILLA INAYAH.S 388,062.0
158 RJ20220209-0001 09/02/2022 OP20220209-0001 2022020900001 TEGAR TRI ATMAJA 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
159 RJ20220209-0002 09/02/2022 OP20220209-0002 2022020900002 CHIARA GRACE. H.S 43,314.0
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
160 RJ20220209-0009 09/02/2022 OP20220209-0015 2022020900011 RAFAEL AGUSTIAN DUHA 5,913.0
R/ COBAZIM 1000MCG 1.00 CAP 5,913.00 5,913.00 0 1

161 RJ20220211-0001 11/02/2022 OP20220211-0001 2022021100001 KAILA PEPAYOSA HUTASOIT 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
162 RJ20220211-0002 11/02/2022 OP20220211-0002 2022021100002 PITRA PRATAMA GURUSINGA 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
163 RJ20220216-0001 16/02/2022 OP20220216-0001 2022021600001 NAURA SYAKIRA ARSYIDINATA 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
164 RJ20220216-0002 16/02/2022 OP20220216-0002 2022021600002 MARIA GISELA NONA 70,331.0
165 RJ20220216-0003 16/02/2022 OP20220216-0004 2022021600003 RIZKY FEBRIAN SIANIPAR 70,331.0
166 RJ20220216-0004 16/02/2022 OP20220216-0004 2022021600004 RIZKY FEBRIAN SIANIPAR 963.0
R/ NALD 25 (ONEMED) 1.00 PCS 660.00 660.00 0 1
167 RJ20220216-0005 16/02/2022 OP20220216-0004 2022021600005 RIZKY FEBRIAN SIANIPAR 363,000.0
R/ VAKSIN VARICELLA 1.00 VIAL 363,000.00 363,000.00 0 0
168 RJ20220218-0001 18/02/2022 OP20220218-0001 2022021800002 NAJWA ALMIRA 137,280.0
R/ FLEET ENEMA 1.00 TUBE 137,280.00 137,280.00 0 1
169 RJ20220221-0011 21/02/2022 OP20220221-0015 2022022100012 SHALYTTA AVICHAYIL DJAGUN 308,344.0
170 RJ20220223-0001 23/02/2022 OP20220223-0001 2022022300002 DIKA ANDRIANTO 528,563.0

OMPUSUNGGU

(OOT)
R/ MOTADERM 10 GR CREAM 1.00 TUBE 1.00 89,375.00 103,481.00 0 1
POT KOSONG 10 ML 2.00 UNT 3,263.00 0.00 0 0
KETOCONAZOLE 10 GR CREAM 1.00 TUBE 7,580.00 0.00 1 0

Kec. Sagulung
Telp : (0778) 3850 332, 3850 268, 0812 7048 6685



Formula Non Formula
171 RJ20220223-0002 23/02/2022 OP20220223-0004 2022022300003 SHYALOMI LETHISIA KHEREN 43,314.0

MANURUNG
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
172 RJ20220225-0001 25/02/2022 OP20220225-0001 2022022500001 WALID MARZUQI SARUMPAET 17,739.0
R/ COBAZIM 1000MCG 3.00 CAP 5,913.00 17,739.00 0 1
173 RJ20220225-0002 25/02/2022 OP20220225-0002 2022022500002 MECHTILDIS NOVELIA AURA 43,314.0

LADDY
R/ COBAZIM 3000MCG 3.00 CAP 14,438.00 43,314.00 0 1
174 RJ20220225-0003 25/02/2022 OP20220225-0003 2022022500003 RAFAEL AGUSTIAN DUHA 72,256.0
SALBUTAMOL 4 MG TAB 4.00 TAB 162.00 0.00 1 0
Total Dokter DR. YURI SP.A 21,015,113.0

Grand Total 188,569,996.0
Jumlah
Non Generik
ormula
17,600.00
295,888.00
143,945.00
194,435.00
70,400.00
8,165.00
183,110.00
0
22,653.00
Jumlah
Non Generik
ormula
58,048.00
26,010.00
58,898.00
10,800.00
89,952.00
Jumlah
Non Generik
ormula
1,500.00
3,350.00
1,500.00
6,350.00
Jumlah
Non Generik
ormula
66,960.00
18,360.00
5,810.00
3,892.00
91,804.00
71,392.00
20,190.00
20,190.00
13,880.00
66,390.00
0
0
Jumlah
Non Generik
ormula
18,644.00
64,190.00
42,360.00
13,880.00
9,960.00
3,892.00
70,282.00
64,190.00
0
3,892.00
Jumlah
Non Generik
ormula
4,820.00
3,892.00
78,870.00
Jumlah
Non Generik
ormula
18,460.00
59,617.00
27.00
4,960.00
14,048.00
7,357.00
2,451.00
69,712.00
37,929.00
0
331,645.00
Jumlah
Non Generik
ormula
47,758.00
10,626.00
7,150.00
17,800.00
213,705.00
25,019.00
137,890.00
0
0
352,515.00
Jumlah
ormula
46,000.00
20,852.00
1,714.00
1,200.00
25,661.00
968,093.00
326,563.00
0
92,000.00
Jumlah
Non Generik
ormula
80,107.00
7,157.00
171,156.00
204,132.00
473,004.00
8,085.00
21,040.00
0
5,075.00
Jumlah
Non Generik
ormula
415,470.00
176,790.00
177,675.00
67,500.00
434,136.00
24,360.00
19,532.00
19,532.00
442,170.00
0
0
0
Jumlah
Non Generik
ormula
152,490.00
555.00
282,738.00
5,075.00
253,440.00
7,024.00
54,137.00
318,048.00
126,529.00
0
0
Jumlah
Non Generik
ormula
46,813.00
79,972.00
7,024.00
102,510.00
555.00
91,059.00
154,286.00
15,400.00
86,604.00
157,533.00
0
Jumlah
Non Generik
ormula
170,111.00
70,315.00
136,486.00
10,626.00
7,150.00
1,850.00
44,000.00
69,500.00
16,006.00
39,999.00
309,280.00
0
0
Jumlah
Non Generik
ormula
56,000.00
305,040.00
61,876.00
61,876.00
10,626.00
187,143.00
39,999.00
861.00
137,505.00
0
110,799.00
Jumlah
Non Generik
ormula
31,288.00
49,575.00
165,872.00
660.00
134,328.00
88,200.00
134,328.00
0
137,505.00
0
Jumlah
Non Generik
ormula
25,771.00
47,738.00
128,538.00
111,622.00
29,298.00
198,715.00
40,827.00
1,813.00
0
76,232.00
0
Jumlah
Non Generik
ormula
31,288.00
71,937.00
157,836.00
28,432.00
13,613.00
388.00
113,488.00
63,360.00
0
Jumlah
Non Generik
ormula
176,018.00
129,492.00
50,418.00
20,909.00
8,900.00
78,361.00
444,611.00
0
0
0
Jumlah
Non Generik
ormula
1,667.00
001,141.00
280,192.00
280,192.00
63,360.00
382,241.00
0
0
0
Jumlah
Non Generik
ormula
21,340.00
2,250.00
39,999.00
60,552.00
69,000.00
69,000.00
69,000.00
139,805.00
87,000.00
45,855.00
0
Jumlah
Non Generik
ormula
118,973.00
319,645.00
8,925.00
1,850.00
2,775.00
4,576.00
1,850.00
84,570.00
0
0
Jumlah
Non Generik
ormula
69,000.00
294,570.00
137,505.00
5,820.00
69,000.00
27,600.00
84,570.00
204,443.00
4,576.00
5,825.00
44,341.00
Jumlah
Non Generik
ormula
92,520.00
119,300.00
206,470.00
245,800.00
204,410.00
253,000.00
41,468.00
0
1
Jumlah
Non Generik
ormula
249,435.00
1,850.00
26,950.00
239,382.00
132,528.00
125,200.00
152,190.00
93,538.00
0
0
0
Jumlah
Non Generik
ormula
142,250.00
228,990.00
20,190.00
339,285.00
242,870.00
197,768.00
63,360.00
0
Jumlah
Non Generik
ormula
1,850.00
190,740.00
63,360.00
61,900.00
159,800.00
64,020.00
190,740.00
17,600.00
0
Jumlah
Non Generik
ormula
15,813.00
138,938.00
66,000.00
82,088.00
7,940.00
224,910.00
58,438.00
69,760.00
136,360.00
0
0
Jumlah
Non Generik
ormula
27,180.00
95,838.00
211,449.00
63,360.00
95,300.00
73,430.00
39,670.00
14,050.00
0
Jumlah
Non Generik
ormula
188,900.00
105,876.00
150,020.00
63,360.00
31,000.00
77,690.00
361,250.00
10,000.00
0
206,470.00
Jumlah
Non Generik
ormula
63,360.00
20,170.00
63,360.00
12,000.00
0.00
388.00
138,080.00
75,528.00
297,460.00
0
0
0
Jumlah
Non Generik
ormula
253,870.00
107,700.00
7,340.00
5,168.00
44,680.00
146,000.00
114,690.00
29,890.00
0
112,198.00
0
Jumlah
Non Generik
ormula
281,020.00
110,276.00
115,360.00
36,910.00
11,990.00
88,410.00
0
0
0
Jumlah
Non Generik
ormula
88,410.00
63,360.00
42,740.00
6,640.00
9,330.00
63,360.00
63,360.00
3,880.00
0
Jumlah
Non Generik
ormula
17,600.00
68,680.00
131,208.00
288,660.00
17,600.00
17,600.00
0.00
13,990.00
0
84,820.00
Jumlah
Non Generik
ormula
521,318.00
251,085.00
313,634.00
78,658.00
73,000.00
0
191,290.00
0
Jumlah
Non Generik
ormula
448,924.00
10,956.00
114,735.00
72,270.00
8,910.00
85,016.00
63,360.00
0
Jumlah
Non Generik
ormula
122,470.00
268,929.00
10,080.00
326,563.00
7,813.00
50,625.00
179,872.00
200,218.00
0
0
0
Jumlah
Non Generik
ormula
160,038.00
60,630.00
67,180.00
8,900.00
190,070.00
238,780.00
8,900.00
8,900.00
231,062.00
0
Jumlah
Non Generik
ormula
208,948.00
244,020.00
17,600.00
134,888.00
116,352.00
148,920.00
377,240.00
0
Jumlah
Non Generik
ormula
20,500.00
494,734.00
73,000.00
284,890.00
83,732.00
46,694.00
1
0
Jumlah
Non Generik
ormula
508,591.00
73,000.00
36,910.00
34,220.00
10,626.00
199,654.00
237,013.00
29,570.00
0
0
Jumlah
Non Generik
ormula
44,773.00
232,446.00
184,569.00
619,360.00
580,805.00
0
0
0
Jumlah
Non Generik
ormula
61,600.00
183,455.00
172,500.00
127,910.00
80,670.00
135,190.00
114,700.00
164,836.00
0
Jumlah
Non Generik
ormula
484,950.00
508,010.00
371,948.00
218,450.00
0
143,000.00
Jumlah
Non Generik
ormula
8,390.00
148,540.00
127,189.00
522,024.00
73,000.00
184,689.00
68,750.00
0
117,280.00
Jumlah
Non Generik
ormula
107,760.00
293,325.00
140,230.00
20,500.00
73,000.00
253,651.00
0
63,360.00
0
Jumlah
Non Generik
ormula
2,448.00
285,979.00
211,200.00
211,200.00
220,049.00
211,200.00
10,830.00
169,932.00
540,594.00
0
0
Jumlah
Non Generik
ormula
191,700.00
282,575.00
61,600.00
83,530.00
20,500.00
61,600.00
456,138.00
0
0
Jumlah
Non Generik
ormula
61,600.00
539,254.00
217,800.00
540,884.00
356,685.00
272,585.00
0
0
Jumlah
Non Generik
ormula
449,280.00
378,968.00
226,406.00
326,319.00
259,550.00
80,000.00
4,685.00
0
0
Jumlah
Non Generik
ormula
45,868.00
73,000.00
336,989.00
401,719.00
344,915.00
15,813.00
22,146.00
0
19,840.00
Jumlah
Non Generik
ormula
169,903.00
62,944.00
302,308.00
35,200.00
20,500.00
72,384.00
Jumlah
Non Generik
ormula
292,600.00
77,350.00
267,790.00
215,590.00
421,335.00
450,380.00
72,934.00
0
Jumlah
Non Generik
ormula
195,620.00
219,700.00
209,790.00
275,924.00
61,990.00
267,790.00
371,900.00
0
0
333,790.00
Jumlah
Non Generik
ormula
113,418.00
108,300.00
62,080.00
85,868.00
98,800.00
77,275.00
70,000.00
274,916.00
0
Jumlah
Non Generik
ormula
52,800.00
84,913.00
93,710.00
168,822.00
104,480.00
63,360.00
93,225.00
Jumlah
Non Generik
ormula
443,470.00
37,540.00
63,360.00
327,470.00
146,445.00
105,678.00
18,360.00
41,260.00
0
Jumlah
Non Generik
ormula
307,380.00
39,296.00
96,939.00
80,000.00
203,210.00
63,360.00
392,240.00
0
0
0
Jumlah
Non Generik
ormula
6,600.00
63,360.00
11,340.00
89,516.00
119,080.00
315,870.00
167,190.00
20,500.00
164,082.00
20,500.00
0
Jumlah
Non Generik
ormula
138,610.00
20,500.00
382,990.00
30,473.00
247,862.00
121,508.00
11,733.00
63,215.00
0
0
0
Jumlah
Non Generik
ormula
272,930.00
101,090.00
395,992.00
167,910.00
77,990.00
86,090.00
0
327,470.00
Jumlah
Non Generik
ormula
76,588.00
153,520.00
78,190.00
64,168.00
143,810.00
310,940.00
305,800.00
0
121,530.00
0
Jumlah
Non Generik
ormula
63,140.00
175,440.00
176,468.00
78,190.00
97,763.00
63,360.00
100,660.00
86,940.00
0
Jumlah
Non Generik
ormula
52,540.00
145,858.00
289,410.00
88,350.00
0
0
0
Jumlah
Non Generik
ormula
148,320.00
20,190.00
65,876.00
315,870.00
377,470.00
155,540.00
0
4,580.00
Jumlah
Non Generik
ormula
155,540.00
155,540.00
100,660.00
217,903.00
46,000.00
28,880.00
110,111.00
1
0
Jumlah
Non Generik
ormula
107,485.00
294,933.00
20,190.00
125,003.00
5,140.00
80,603.00
0
0
0
Jumlah
Non Generik
ormula
295,275.00
212,570.00
154,575.00
315,870.00
51,820.00
175,859.00
0
0
Jumlah
Non Generik
ormula
100,190.00
85,140.00
28,040.00
197,870.00
39,500.00
95,140.00
323,770.00
85,140.00
10.00
0
Jumlah
Non Generik
ormula
189,178.00
387,358.00
3,880.00
190,998.00
462,870.00
120,140.00
3,880.00
0
Jumlah
Non Generik
ormula
136,810.00
35,715.00
9,973.00
119,080.00
197,070.00
128,040.00
36,910.00
141,860.00
4,580.00
0
Jumlah
Non Generik
ormula
20,500.00
315,870.00
4,576.00
105,463.00
3,880.00
20,500.00
250,113.00
250,113.00
70,700.00
0
0
Jumlah
Non Generik
ormula
2,460.00
134,420.00
66,510.00
58,710.00
305,970.00
251,715.00
89,519.00
Jumlah
Non Generik
ormula
116,850.00
1,310.00
8,100.00
12,180.00
17,800.00
102,215.00
41,568.00
150,240.00
548,071.00
0
0
0
Jumlah
Non Generik
ormula
64,643.00
101,902.00
38,056.00
885.00
92,760.00
521,157.00
7,160.00
0
0
Jumlah
Non Generik
ormula
185.00
90,283.00
658,660.00
1,000.00
582,025.00
23,788.00
7,800.00
98,900.00
0
0
0
Jumlah
Non Generik
ormula
45,377.00
846,946.00
37,098.00
6,519.00
7,800.00
77,440.00
44,500.00
19,532.00
45,360.00
83,029.00
0
Jumlah
Non Generik
ormula
38,198.00
547,495.00
259,223.00
8,970.00
152,822.00
0
0
0
Jumlah
Non Generik
ormula
1,770.00
13,333.00
7,157.00
50,882.00
556,420.00
96,505.00
65,628.00
0
0
0
Jumlah
Non Generik
ormula
1,770.00
29,597.00
17,800.00
29,700.00
25,344.00
885.00
75,120.00
13,435.00
98,441.00
112,680.00
0
Jumlah
Non Generik
ormula
51,734.00
84,648.00
61,161.00
227,685.00
13,333.00
61,187.00
37,580.00
29,298.00
0
39,999.00
Jumlah
Non Generik
ormula
349,167.00
94,428.00
133,975.00
9,533.00
19,600.00
2,451.00
2,140.00
84,480.00
675.00
0
Jumlah
Non Generik
ormula
102,916.00
337,920.00
5,804.00
112,680.00
33,600.00
42,324.00
42,324.00
685.00
1,485.00
13,333.00
73,126.00
0
0
Jumlah
Non Generik
ormula
41,514.00
142,835.00
97,278.00
233,921.00
205,065.00
0
0
Jumlah
Non Generik
48,284.00
106,689.00
198,486.00
198,486.00
338,968.00
29,700.00
25,195.00
0
0
0
Jumlah
Non Generik
ormula
8,850.00
4,050.00
168,960.00
10,626.00
2,025.00
13,720.00
126,720.00
63,360.00
96,498.00
265,813.00
0
0
0
Jumlah
Non Generik
ormula
150,950.00
38,894.00
162,000.00
162,000.00
8,085.00
83,088.00
4,455.00
0
1,200.00
Jumlah
Non Generik
ormula
21,252.00
8,850.00
331,833.00
444,522.00
136,610.00
254,440.00
17,800.00
0
225,786.00
Jumlah
Non Generik
ormula
47,664.00
888,394.00
21,040.00
16,134.00
32,715.00
21,952.00
0
0
0
Jumlah
Non Generik
ormula
700,228.00
27,822.00
48,573.00
44,500.00
26,003.00
2,603.00
83,070.00
0
Jumlah
Non Generik
ormula
122,448.00
21,600.00
13,720.00
21,600.00
10,800.00
1,485.00
20,134.00
22,484.00
488,472.00
16,772.00
0
0
0
Jumlah
Non Generik
ormula
42,324.00
104,732.00
52,697.00
97,818.00
677,818.00
675,218.00
0
0
Jumlah
Non Generik
ormula
5,430.00
145,800.00
145,800.00
24,200.00
52,855.00
406,094.00
247,101.00
0
0
0
Jumlah
Non Generik
ormula
162,730.00
482,974.00
73,042.00
476,533.00
0
0
0
Jumlah
Non Generik
ormula
144,486.00
42,324.00
33,915.00
66,570.00
634,979.00
13,275.00
66,468.00
437,556.00
0
0
0
Jumlah
Non Generik
ormula
27,150.00
14,000.00
10,160.00
30,000.00
52,377.00
6,930.00
555.00
25,770.00
19,532.00
59,187.00
0
0
118,617.00
Jumlah
Non Generik
ormula
490,533.00
413,388.00
36,570.00
67,843.00
0
0
0
Jumlah
Non Generik
ormula
491,913.00
29,784.00
555.00
52,800.00
52,800.00
217,379.00
162,741.00
0
0
0
Jumlah
Non Generik
ormula
14,760.00
13,333.00
62,967.00
105,810.00
31,286.00
10,000.00
13,741.00
228,141.00
0
0
0
Jumlah
Non Generik
ormula
63,507.00
735,249.00
67,136.00
61,008.00
0
21,600.00
Jumlah
Non Generik
ormula
61,867.00
50,219.00
25,190.00
273,815.00
8,850.00
8,250.00
130,210.00
0
Jumlah
Non Generik
ormula
21,600.00
63,360.00
6,930.00
7,803.00
57,200.00
21,803.00
7,803.00
63,360.00
885.00
293,843.00
0
0
0
Jumlah
Non Generik
ormula
878,452.00
13,720.00
158,644.00
124,545.00
0
Jumlah
Non Generik
ormula
591,048.00
56,882.00
171,422.00
0
167,603.00
Jumlah
Non Generik
ormula
161,051.00
62,901.00
66,003.00
736,053.00
0
0
0
Jumlah
Non Generik
ormula
110,467.00
81,364.00
2,451.00
52,800.00
5,075.00
254,524.00
217,800.00
550.00
36,855.00
13,720.00
0
Jumlah
Non Generik
ormula
501,258.00
72,900.00
194,400.00
194,400.00
194,400.00
19,532.00
34,860.00
660.00
5,373.00
39,999.00
80,658.00
0
0
0
Jumlah
Non Generik
ormula
42,294.00
44,397.00
652,112.00
516,594.00
288,877.00
0
Jumlah
Non Generik
ormula
691,228.00
892,635.00
453,284.00
0
0
0
Jumlah
Non Generik
ormula
136,527.00
535,352.00
21,803.00
12,730.00
26,480.00
0
14,000.00
0
Jumlah
Non Generik
ormula
122,170.00
25,626.00
8,100.00
42,080.00
6,664.00
3,003.00
2,750.00
34,860.00
13,720.00
9,876.00
0
0
0
Jumlah
Non Generik
ormula
39,999.00
243,179.00
32,400.00
165,003.00
574,302.00
496,247.00
0
0
0
Jumlah
Non Generik
ormula
355,327.00
561,299.00
809,560.00
83,782.00
103,238.00
0
Jumlah
Non Generik
ormula
21,803.00
708,991.00
24,360.00
77,486.00
77,486.00
56,700.00
14,670.00
15,900.00
3,003.00
0
Jumlah
Non Generik
ormula
68,010.00
84,585.00
69,720.00
20,490.00
42,080.00
21,040.00
4,050.00
26,939.00
63,360.00
13,993.00
0
1
Jumlah
Non Generik
ormula
18,688.00
186,502.00
207,266.00
50,188.00
509,373.00
0
0
0
Jumlah
Non Generik
ormula
801,426.00
45,370.00
42,715.00
172,778.00
31,264.00
0
Jumlah
Non Generik
ormula
442,633.00
476,473.00
10,225.00
125,361.00
2,655.00
0
46,380.00
0
Jumlah
Non Generik
ormula
6,930.00
8,942.00
100,000.00
100,000.00
20,790.00
1,000.00
1,485.00
1,485.00
1,485.00
1,485.00
885.00
12,786.00
0
0
Jumlah
Non Generik
ormula
62,088.00
8,132.00
257,474.00
209,052.00
303,461.00
0
0
0
Jumlah
Non Generik
ormula
306,546.00
156,252.00
251,687.00
13,107.00
0
0
Jumlah
Non Generik
ormula
354,852.00
252,921.00
544,901.00
62,665.00
71,350.00
0
0
0
Jumlah
Non Generik
ormula
4,850.00
12,258.00
13,422.00
81,867.00
16,077.00
13,422.00
12,258.00
0
0
0
Jumlah
Non Generik
ormula
12,258.00
144,615.00
181,809.00
129,009.00
145,800.00
145,800.00
4,455.00
310,366.00
0
0
81,864.00
Jumlah
Non Generik
ormula
81,779.00
160,500.00
87,600.00
87,600.00
7,803.00
7,150.00
54,625.00
20,533.00
0
424,762.00
Jumlah
Non Generik
ormula
51,150.00
614,524.00
32,400.00
5,001.00
62,417.00
21,600.00
0
67,500.00
0
Jumlah
Non Generik
ormula
31,600.00
196,120.00
9,318.00
854,147.00
7,150.00
0
Jumlah
Non Generik
ormula
128,130.00
120,315.00
294.00
21,040.00
12,180.00
1,667.00
48,555.00
97,972.00
19,729.00
0
0
1
Jumlah
Non Generik
ormula
319,574.00
912,631.00
52,927.00
52,800.00
327,992.00
0
0
Jumlah
Non Generik
ormula
372,298.00
23,788.00
2,775.00
368,356.00
185,010.00
8,085.00
15,975.00
76,434.00
0
0
0
Jumlah
Non Generik
ormula
7,329.00
5,140.00
13,275.00
13,275.00
40,035.00
70,000.00
47,650.00
17,020.00
91,059.00
8,850.00
497,424.00
0
0
Jumlah
Non Generik
ormula
8,981.00
507,340.00
7,160.00
85,984.00
115,500.00
4,650.00
16,975.00
2,058.00
13,275.00
8,175.00
0
61,188.00
0
Jumlah
Non Generik
ormula
591,885.00
1,850.00
54,781.00
233,481.00
74,051.00
5,310.00
236,551.00
5,310.00
0
Jumlah
Non Generik
ormula
388,712.00
16,142.00
53,038.00
8,850.00
5,820.00
13,275.00
71,220.00
8,996.00
29,509.00
190,180.00
0
Jumlah
Non Generik
ormula
5,820.00
106,575.00
108,405.00
13,020.00
1,925.00
65,220.00
5,310.00
38,562.00
Jumlah
Non Generik
ormula
204,966.00
20,500.00
8,158.00
272,516.00
4,741.00
291,788.00
208,744.00
1
47,105.00
Jumlah
Non Generik
ormula
178,530.00
11,242.00
266,472.00
4,020.00
205,520.00
82,500.00
32,274.00
0
0
120,002.00
Jumlah
Non Generik
ormula
24,940.00
2,600.00
92,773.00
255,910.00
29,619.00
87,474.00
401,402.00
0
0
0
Jumlah
Non Generik
ormula
1,850.00
13,190.00
36,788.00
18,420.00
140,170.00
21,493.00
4,580.00
60,500.00
66,112.00
20,500.00
0
131,014.00
Jumlah
Non Generik
ormula
158,978.00
267,290.00
323,438.00
234,432.00
117,153.00
394,680.00
0
0
0
Jumlah
Non Generik
ormula
208,292.00
271,076.00
28,461.00
41,368.00
243,504.00
217,405.00
127,194.00
0
Jumlah
Non Generik
ormula
119,122.00
1,850.00
13,710.00
164,082.00
32,489.00
153,315.00
213,186.00
0
0
0
Jumlah
Non Generik
ormula
393,220.00
210,032.00
196,272.00
89,773.00
278,182.00
176,932.00
0
0
Jumlah
Non Generik
ormula
284,178.00
148,150.00
234,432.00
58,438.00
174,232.00
10,100.00
104,740.00
221,470.00
0
0
Jumlah
Non Generik
ormula
168,296.00
194,440.00
23,650.00
35,733.00
92,061.00
56,320.00
23,486.00
23,486.00
0
0
Jumlah
Non Generik
ormula
10,626.00
10,626.00
101,036.00
92,430.00
58,438.00
65,220.00
132,012.00
68,874.00
0
148,122.00
0
Jumlah
Non Generik
ormula
119,122.00
70,350.00
101,000.00
129,212.00
56,496.00
270,878.00
0
0
0
Jumlah
Non Generik
ormula
20,500.00
295,148.00
9,269.00
72,978.00
206,470.00
155,452.00
88,530.00
0
219,186.00
0
Jumlah
Non Generik
ormula
146,030.00
70,950.00
262,776.00
129,962.00
161,892.00
60,000.00
187,398.00
0
0
Jumlah
Non Generik
ormula
40,891.00
185,478.00
37,746.00
271,128.00
24,360.00
24,520.00
61,580.00
113,972.00
0
0
Jumlah
Non Generik
ormula
159,102.00
160,583.00
191,260.00
24,360.00
250,604.00
63,527.00
17,600.00
38,100.00
0
Jumlah
Non Generik
ormula
119,122.00
141,362.00
228,716.00
104,580.00
218,282.00
152,103.00
125,768.00
0
0
Jumlah
Non Generik
ormula
263,112.00
109,288.00
280,124.00
266,472.00
1,375.00
110,803.00
209,614.00
0
Jumlah
Non Generik
ormula
60,000.00
37,780.00
183,485.00
360,780.00
248,638.00
92,430.00
190,122.00
0
0
190,122.00
Jumlah
Non Generik
ormula
111,052.00
23,978.00
316,004.00
21,493.00
12,908.00
81,770.00
0
220,682.00
0
Jumlah
Non Generik
ormula
10,000.00
190,412.00
113,664.00
215,982.00
110,423.00
52,953.00
111,360.00
0
0
Jumlah
Non Generik
ormula
259,457.00
50,150.00
134,570.00
266,930.00
300,482.00
130,270.00
3,880.00
0
112,746.00
Jumlah
Non Generik
ormula
108,720.00
2,750.00
206,302.00
66,758.00
5,610.00
27,500.00
36,835.00
177,512.00
0
0
Jumlah
Non Generik
ormula
18,940.00
115,000.00
11,733.00
88,530.00
41,486.00
135,190.00
268,782.00
264,450.00
0
122,740.00
Jumlah
Non Generik
ormula
11,050.00
136,978.00
5,450.00
187,810.00
194,894.00
16,088.00
4,680.00
274,302.00
0
116,646.00
Jumlah
Non Generik
ormula
252,247.00
35,200.00
218,248.00
30,473.00
11,003.00
Jumlah
Non Generik
ormula
258,284.00
19,532.00
118,652.00
166,627.00
320,191.00
0
24,360.00
0
Jumlah
Non Generik
ormula
462,420.00
1,485.00
46,586.00
230,813.00
0
24,975.00
Jumlah
Non Generik
ormula
115,914.00
20,936.00
33,320.00
12,255.00
4,455.00
7,800.00
65,000.00
24,360.00
1,667.00
42,680.00
0
Jumlah
Non Generik
ormula
35,750.00
46,200.00
683,190.00
167,190.00
683,190.00
167,190.00
85,022.00
Jumlah
Non Generik
ormula
14,260.00
63,360.00
71,920.00
388,200.00
361,670.00
245,588.00
17,600.00
0
Jumlah
Non Generik
ormula
24,050.00
63,360.00
94,570.00
85,704.00
201,870.00
297,460.00
62,180.00
55,950.00
0
Jumlah
Non Generik
ormula
4,980.00
80,690.00
60,030.00
63,360.00
63,360.00
32,975.00
96,910.00
16,950.00
0
0
0
Jumlah
Non Generik
ormula
75,460.00
117,698.00
11,500.00
63,360.00
206,470.00
216,420.00
204,410.00
6,280.00
0
Jumlah
Non Generik
ormula
12.00
63,360.00
98,250.00
272,540.00
240,470.00
60,835.00
Jumlah
Non Generik
ormula
82,000.00
41,000.00
348,475.00
69,015.00
268,833.00
34,023.00
389,219.00
0
117,614.00
Jumlah
Non Generik
ormula
20,625.00
156,559.00
76,350.00
109,030.00
29,298.00
209,318.00
63,015.00
0
Jumlah
Non Generik
ormula
286,645.00
17,739.00
17,739.00
75,120.00
75,000.00
63,015.00
114,195.00
165,553.00
33,468.00
0
0
0
Jumlah
Non Generik
ormula
30,813.00
1,770.00
156,006.00
235,123.00
37,560.00
197,525.00
285,680.00
0
52,938.00
0
Jumlah
Non Generik
ormula
17,739.00
19,589.00
259,240.00
20,625.00
110,550.00
41,000.00
41,000.00
132,786.00
9,036.00
0
196,010.00
Jumlah
Non Generik
ormula
44,239.00
17,739.00
75,000.00
9,009.00
94,993.00
196,010.00
68,400.00
17,739.00
75,000.00
63,015.00
75,000.00
0
28,875.00
Jumlah
Non Generik
ormula
41,000.00
75,000.00
61,500.00
43,314.00
804,199.00
61,500.00
74,318.00
320,881.00
0
0
0
Jumlah
Non Generik
ormula
41,337.00
555.00
804,053.00
512,150.00
28,324.00
498,601.00
0
0
0
Jumlah
Non Generik
ormula
42,515.00
4,568.00
156,888.00
21,600.00
22,106.00
88,530.00
4.00
1,028.00
206,250.00
21,600.00
633,600.00
0
0
Jumlah
Non Generik
ormula
51,040.00
426,640.00
41,000.00
28,541.00
6,006.00
33,684.00
92,959.00
356,987.00
0
50,150.00
Jumlah
Non Generik
ormula
84,300.00
41,000.00
41,000.00
6,006.00
156,888.00
555.00
632,765.00
134,031.00
204,362.00
0
1,850.00
Jumlah
Non Generik
ormula
372,650.00
299,760.00
47,678.00
286,500.00
41,000.00
294,215.00
266,000.00
861.00
117,606.00
0
0
Jumlah
Non Generik
ormula
166,230.00
63,810.00
307,330.00
75,000.00
7,333.00
225,000.00
75,000.00
225,000.00
61,500.00
61,500.00
61,500.00
0
Jumlah
Non Generik
ormula
104,418.00
84,300.00
154,215.00
233,900.00
202,000.00
199,900.00
199,900.00
75,000.00
97,657.00
0
0
0
Jumlah
Non Generik
ormula
22,106.00
50,150.00
8,900.00
43,314.00
71,486.00
37,206.00
3,003.00
196,253.00
150,000.00
43,314.00
3,003.00
0
Jumlah
Non Generik
ormula
20,500.00
215,444.00
13,000.00
6,500.00
41,000.00
538,200.00
3,003.00
41,000.00
47,006.00
191,000.00
0
41,000.00
Jumlah
Non Generik
ormula
1,467.00
2,419.00
1,813.00
17,739.00
43,314.00
50,150.00
388,062.00
17,739.00
43,314.00
5,913.00
0
17,739.00
0
Jumlah
Non Generik
ormula
17,739.00
17,739.00
70,331.00
70,331.00
963.00
363,000.00
137,280.00
308,344.00
528,563.00
0
1
0
Jumlah
Non Generik
ormula
43,314.00
17,739.00
43,314.00
72,256.00
15,113.00
69,996.00

Dokter 5

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Dokter 5

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RS SANTA ELISABETH SEI LEKOP

Kav. Sungai Lekop Kel. Sungai Lekop

Laporan Penjualan Resep Rawat Darurat Per Dokter

Jenis resep : Rawat Darurat

R/ Nama Item Qty Satuan Harga Jumlah Generik Non Gene

Dokter : DR. ANDI EKA PUTRA

1 RD20220203-0001 03/02/2022 EP20220203-0001 2022020300001 MUHAMMAD AVATAR 17,600.0

R/ PAMOL 125 MG SUPP 1.00 SUPP 17,600.00 17,600.00 0 1

2 RD20220203-0002 03/02/2022 EP20220203-0001 2022020300002 MUHAMMAD AVATAR 295,888.0

R/ RHINOS JUNIOR SYR (PREK) 1.00 BTL 52,800.00 52,800.00 0 0

R/ SANMOL 60 ML SYR 1.00 FLS 16,088.00 16,088.00 0 1

R/ ISPRINOL 60 ML SYR 1.00 FLS 110,000.00 110,000.00 0 1

R/ PROZA SYR 1.00 FLS 117,000.00 117,000.00 0 1

3 RD20220203-0003 03/02/2022 EP20220203-0002 2022020300003 KEVIN ANJASWANA SILABAN 143,945.0

R/ LAPRAZ 30 MG CAP 5.00 CAP 16,473.00 82,365.00 0 1

R/ SANMOL 500 MG TABLET 10.00 TAB 408.00 4,080.00 0 1

R/ PROZA KAPLET 5.00 KAPLET 11,500.00 57,500.00 0 1

4 RD20220216-0034 16/02/2022 EP20220216-0033 2022021600057 RUTH MONICA SIHOTANG 194,435.0

R/ PROPEPSA 100 ML SYR 1.00 FLS 83,070.00 83,070.00 0 1

R/ PROVITAL PLUS CAPS 5.00 CAP 5,800.00 29,000.00 0 1

R/ LAPRAZ 30 MG CAP 5.00 CAP 16,473.00 82,365.00 0 1

5 RD20220216-0035 16/02/2022 EP20220216-0034 2022021600058 SABINA ARTINDIRANI PUTRI 70,400.0

R/ RHINOS NEO DROP (PREK) 1.00 FLS 70,400.00 70,400.00 0 0

6 RD20220217-0002 17/02/2022 EP20220217-0002 2022021700002 M.NUR ALIF ADI TRIANSYAH 8,165.0

R/ PARACETAMOL 500 MG 4.00 KAPLET 185.00 740.00 1 0

R/ CETIRIZINE 10 MG TAB 5.00 TAB 1,000.00 5,000.00 1 0

R/ KERTAS PERKAMEN BERLOGO 10.00 LBR 1.00 100.00 1,000.00 0 1

7 RD20220217-0003 17/02/2022 EP20220217-0003 2022021700005 NOPASARI SILITONGA 183,110.0

R/ ACETYLCYSTEIN 200 MG 10.00 CAP 1,485.00 14,850.00 1 0

R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

R/ RHINOS SR KAPSUL 10.00 CAP 8,067.00 80,670.00 0 1

R/ VITAMIN C XON-CE KAPLET 10.00 KAPLET 1.00 10.00 0 1

Print Date:7/14/2022 Print Time: 2:11:10PM Page 1 of 190

Laporan Penjualan Resep Rawat Darurat Per Dokter

Jenis resep : Rawat Darurat

R/ Nama Item Qty Satuan Harga Jumlah Generik Non Gene

R/ DOMPERIDON 60 ML SYR 1.00 FLS 15,813.00 15,813.00 1 0

R/ PARACETAMOL SYR 60 ML 1.00 FLS 6,840.00 6,840.00 1 0

9 RD20220217-0005 17/02/2022 EP20220217-0006 2022021700010 IMAM NAWAWI 58,048.0

R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

R/ VITAMIN C XON-CE KAPLET 10.00 KAPLET 1.00 10.00 0 1

R/ RANITIDINE 150 MG TAB 10.00 TAB 200.00 2,000.00 1 0

R/ TREMENZA 60 ML SYR (PREK) 1.00 FLS 28,188.00 28,188.00 0 1

R/ PARACETAMOL 500 MG 10.00 KAPLET 185.00 1,850.00 1 0

R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

R/ VITAMIN C XON-CE KAPLET 10.00 KAPLET 1.00 10.00 0 1

11 RD20220217-0007 17/02/2022 EP20220217-0007 2022021700019 JEFRI ROLLI RICHARDO 58,898.0

R/ TREMENZA 60 ML SYR (PREK) 1.00 FLS 28,188.00 28,188.00 0 1

R/ DEVIT 1000 IU 10.00 TAB 2,600.00 26,000.00 0 1

R/ PARACETAMOL 500 MG 10.00 KAPLET 185.00 1,850.00 1 0

R/ VITAMIN C XON-CE KAPLET 10.00 KAPLET 1.00 10.00 0 1

12 RD20220217-0030 17/02/2022 EP20220217-0007 2022021700065 JEFRI ROLLI RICHARDO 10,800.0

R/ ASERING 500 ML INF 1.00 FLS 10,800.00 10,800.00 0 1

Total Dokter DR. ANDI EKA PUTRA 1,089,952.0

Laporan Penjualan Resep Rawat Jalan Per Dokter

Jenis resep : Rawat Jalan

R/ Nama Item Qty Satuan Harga Jumlah Generik Non Gene

Dokter : DR. BERNARD PARDOMUAN PURBA, SPB

1 RJ20220202-0008 02/02/2022 OP20220202-0014 2022020200014 BREMA S.P TUMANGGOR 1,500.0

R/ VITAMIN B COMPLEX TAB 10.00 TAB 150.00 1,500.00 1 0

2 RJ20220202-0009 02/02/2022 OP20220202-0015 2022020200015 SUMAIRI 3,350.0

R/ VITAMIN B COMPLEX TAB 10.00 TAB 150.00 1,500.00 1 0

R/ PARACETAMOL 500 MG 10.00 KAPLET 185.00 1,850.00 1 0