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  • Format Permohonan Update Data PBF

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    Jaya Farma
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    This document is a request form from PT. Sejahtera Mulia Farma for updating administrative data. It requests information such as the name, address, phone number, and tax ID of the medical facility as well as the names, licenses, and contact information of the pharmacist manager, assistant pharmacists, and required document attachments. Signatures and stamps are also included to verify the information provided.

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    Format Permohonan Update Data PBF (1) (1)

    Original Title

    Format Permohonan Update Data PBF (1) (1)

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    This document is a request form from PT. Sejahtera Mulia Farma for updating administrative data. It requests information such as the name, address, phone number, and tax ID of the medical facility as well as the names, licenses, and contact information of the pharmacist manager, assistant pharmacists, and required document attachments. Signatures and stamps are also included to verify the information provided.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views2 pages

    Format Permohonan Update Data PBF

    Uploaded by

    Jaya Farma
    This document is a request form from PT. Sejahtera Mulia Farma for updating administrative data. It requests information such as the name, address, phone number, and tax ID of the medical facility as well as the names, licenses, and contact information of the pharmacist manager, assistant pharmacists, and required document attachments. Signatures and stamps are also included to verify the information provided.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    PT.

    SEJAHTERA MULIA FARMA


    Jl. Ir. Sutami Blok LL No.02 Samarinda
    Hp. 0858 2135 4867
    Email : sejahteramuliafarma@gmail.com

    PERMOHONAN UPDATE DATA ADMINISTRASI PT. SEJAHTERA MULIA FARMA

    NamaSarana
    (Apotek/PBF/RS/Klinik) : _____________________________________________

    Alamat : _____________________________________________

    Telepon / Fax : _____________________________________________

    NamaPemilikSarana/ Pimpinan : _____________________________________________

    No NPWP di Faktur Pajak : _____________________________________________

    NamaApotekerPengelola /
    Penanggungjawab : _____________________________________________

    No. IjinSarana / Berlaku s/d (*FC) : _____________________________________________

    Kode Unit LayananSIPNAP/e-report : _____________________________________________

    Alamat Apoteker APA/APJ : _____________________________________________

    No. Telp / HP APA/APJ : _____________________________________________


    Spesimen
    1 NamaApotekerPenanggungjawab
    Nomor SIPA / SIKA
    Nomor HP
    Paraf APA / APJ TTD APA / APJ StempelSarana

    NamaApotekerPendamping
    2
    Nomor SIPA / SIKA
    Nomor HP
    ParafAPING TTD APING StempelSarana

    3 AsistenApoteker 1 AsistenApoteker 2
    Nama: Nama:
    Nomor SIK TTK : Nomor SIK TTK :
    Alamat : Alamat :

    No. Telp/HP : No. Telp/HP :

    Paraf TandaTangan Paraf TandaTangan


    PT. SEJAHTERA MULIA FARMA
    Jl. Ir. Sutami Blok LL No.02 Samarinda
    Hp. 0858 2135 4867
    Email : sejahteramuliafarma@gmail.com

    DokumenPelengkap : - FotokopiSuratIjinKlinik / Apotek


    - FotokopiSuratIjinPraktekApoteker (Penanggungjawabdanpendamping)
    - FotokopiSuratIjinKerjaTenagaTeknisKefarmasianAsistenApoteker
    - Fotokopi NPWP

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