LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

DINAS KESEHATAN KABUPATEN MALANG

PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00 10
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00 13
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00 10
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00 3
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI SENGKRA SUMBER PONKES
KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

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 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

PONKESD
POS POS ES
SENGKRA KALIREJO SUMBER PONKES PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00 210 250 460
2 Adalat Oros 20 mg TABLET Rp 3,255.00 6 990 30 30 30 30 30 30 70 30 50 60 60 30 30 30 150 30 30 1746
3 Albendazol 400 mg TABLET Rp - 1260 1260
4 Alopurinol 100 mg TABLET Rp 90.00 120 12480 100 270 110 100 150 195 10 240 370 150 360 70 80 50 300 100 15255
5 Alopurinol 300 mg TABLET Rp 210.00 140 2500 50 200 200 200 100 100 50 3540
6 Ambroxol 30 mg TABLET Rp 100.00 280 2800 200 46 110 141 200 200 290 150 200 200 165 100 130 200 200 190 100 5902
7 Amlodipin 5 mg TABLET Rp 105.00 50 18510 44 25 400 50 50 50 19179
8 Amlodipin 10 mg TABLET Rp 104.00 2940 2940
9 Aminofilina 200 mg TABLET Rp 91.00 85 2100 123 100 100 70 100 100 100 100 100 9 100 3187
10 Amoksilin 250 mg KAPSUL Rp 195.00 130 130
11 Amoksilin 500 mg KAPLET Rp 232.00 200 11300 326 100 130 700 300 300 460 600 500 1000 365 460 270 320 325 1550 100 19306
12 Antalgin 500 mg TABLET Rp - 1300 370 100 1770
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00 480 200 12100 100 333 160 248 500 200 250 730 500 340 530 340 460 170 390 700 100 18831
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00 30 30
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00 0
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00 2390 20 100 100 100 100 130 110 100 150 100 30 100 3530
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00 130 216 270 178 250 300 310 200 200 160 290 220 300 180 103 100 100 3507
18 Asam folat 1 mg TABLET Rp 67.00 100 140 100 100 100 270 33 100 943
19 Asam mefenamat 500mg TABLET Rp 106.00 200 14370 344 80 170 700 200 280 340 500 300 790 300 480 240 300 315 800 100 20809
20 Asetosal 100 mg TABLET Rp 130.00 100 100 200
21 Asiklovir 400mg TABLET Rp 349.00 80 750 50 140 30 100 60 40 150 200 345 240 130 50 150 12 148 100 2775
22 Betahistin mesilat 5 mg TABLET Rp 149.00 1130 30 50 35 30 30 40 40 30 90 110 80 50 110 30 30 1915
23 Bisoprolol tablet 5 mg TABLET Rp 330.00 1000 1000
24 Bromhexin 8 mg TABLET 600 100 700
25 Cefadroxil 500 mg KAPSUL Rp 516.00 2900 2900
26 Cetirizin 10mg TABLET Rp 143.00 800 38 30 30 30 80 100 60 30 30 1228
27 Deksametason 0,5 mg TABLET Rp 44.00 140 9580 332 140 132 500 150 280 170 200 630 285 300 200 400 212 400 100 14151
28 Dekstrometorfan 15 mg TABLET Rp - 0
29 Digoksin 0,25 mg TABLET Rp 105.00 140 140
30 Diltiazem 30 mg TABLET Rp 127.00 88 88
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00 85 2000 50 152 35 100 130 120 223 100 50 75 50 50 3220
32 Doksisiklin 100mg KAPSUL Rp 268.00 300 100 400
33 Domperidon tablet 10 mg TABLET Rp 118.00 70 120 2220 50 100 100 130 40 120 30 30 200 3210
34 Efedrin HCL 25 mg TABLET Rp 47.00 58 58
35 Eritromisin 500mg KAPLET Rp 730.00 60 1690 50 45 100 100 150 100 50 2345
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00 1070 35 30 40 70 90 150 90 50 90 165 1880
37 Furosemid 40 mg TABLET Rp 78.00 80 4280 80 104 20 57 100 170 4891
38 Gemfibrozil 600mg TABLET 2600 2600
39 Glibenklamide 5mg TABLET Rp 100.00 80 3180 100 100 80 90 200 230 60 100 210 280 200 40 100 230 100 5380
40 Glimepiride tablet 2 mg TABLET Rp 289.00 4250 70 4320
41 Gliseril Guaiakolat 100 mg TABLET Rp - 2670 244 160 64 200 110 221 300 200 200 209 200 196 50 100 5124
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
42 Griseofulvin 125 mg TABLET Rp 245.00 200 30 30 260
43 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00 5200 146 100 5446
44 Hyosin N Butilbromida 10mg TABLET Rp 300.00 100 300 100 500
45 Ibuprofen 400 mg TABLET Rp 127.00 170 11800 180 366 100 300 210 200 220 300 330 620 340 390 250 200 430 100 16506
46 Ibuprofen 200 mg TABLET Rp 105.00 1250 68 140 180 300 180 200 300 200 290 150 210 200 500 100 4268
47 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00 100 500 30 630
48 Kalium Diklofenac 50mg TABLET Rp 200.00 10 10
49 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00 76 70 3280 110 114 110 190 200 100 180 100 100 330 150 160 100 240 110 100 100 5920
50 Kaptopril 25 mg TABLET Rp 80.00 110 200 10 40 100 20 70 130 20 700
51 Kaptopril 12,5 mg TABLET Rp 62.00 280 149 110 210 200 20 80 250 140 220 290 210 230 360 100 210 100 3159
52 Ketokonazol 200mg tablet TABLET Rp 280.00 830 40 70 150 20 20 100 50 50 120 130 30 22 50 1682
53 Klindamisin kapsul 300 mg KAPSUL Rp 361.00 40 10 50
54 Klopidogrel TABLET Rp 2,000.00 24 24
55 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00 80 4000 200 455 400 200 300 200 330 360 300 300 200 225 452 400 480 301 200 200 9583
56 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00 9 100 37680 338 70 148 500 100 170 305 300 780 300 230 1000 500 500 100 43130
57 Klorokuin tablet 150 mg TABLET Rp - 0
58 Klorpropamid tablet 100 mg TABLET Rp - 70 70
59 Kotrimoksazol anak TABLET
(Sulfametoksazol100mg+Trimetoprim20mg) Rp - 0

60 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00 60 10800 287 155 100 200 40 156 230 200 300 257 234 170 290 440 360 100 14379
61 Levofloksasin 500 mg TABLET Rp 495.00 5 1250 120 1375
62 Lisinopril 5mg tablet TABLET Rp 269.00 400 50 450
63 Loratadin tablet 10 mg TABLET Rp 134.00 80 500 78 50 50 50 50 50 50 50 1008
64 Mebendazol tablet 100 mg TABLET Rp - 73 100 173
65 Meloksikam tablet 7,5 mg TABLET Rp 629.00 50 1700 108 70 100 2028
66 Metformin 500mg tablet TABLET Rp 100.00 5500 100 120 50 100 120 120 200 300 170 250 100 100 100 100 50 7480
67 Metil Prednisolon 4 mg TABLET Rp 194.00 100 4700 50 64 100 100 50 100 250 210 120 100 165 50 6159
68 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00 80 800 50 200 100 100 40 50 1420
69 Metoklopramid 5mg TABLET Rp 123.00 2500 26 70 30 60 2686
70 Metronidazol 250 mg TABLET Rp 78.00 60 120 180
71 Metronidazol 500mg TABLET Rp 133.00 18 8180 100 142 85 130 200 270 100 200 300 350 140 190 75 180 124 100 10884
72 N - Asetylsistein KAPSUL Rp 1,100.00 1200 1200
73 Natrium Diklofenac 25 mg TABLET Rp 132.00 35 35
74 Natrium Diklofenac 50 mg TABLET Rp 159.00 70 2620 150 128 70 200 100 100 130 90 100 100 100 150 100 100 40 100 190 100 4738
75 Nifedipin 10 mg tablet TABLET Rp 104.00 70 1020 58 40 120 20 90 200 194 50 100 1962
76 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00 60 6 8 1 10 5 2 4 5 10 111
77 Omeprazole 20mg TABLET Rp 160.00 7 90 3720 30 21 30 90 160 150 230 140 40 60 120 90 30 60 5068
78 Ondansetron tab TABLET Rp 160.00 2700 2700
79 Parasetamol 100 mg TABLET Rp 200.00 0
80 Parasetamol 500 mg TABLET Rp 56.00 100 30200 200 496 200 320 500 200 100 380 500 400 520 256 515 205 750 800 1470 200 38312
81 Pirantel 125 mg TABLET Rp 269.00 0
82 Pirasetam 800 mg tablet TABLET Rp 62.00 1600 46 1646
83 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00 70 6100 34 73 100 130 170 170 100 6947
84 Prednison tablet 5 mg TABLET Rp 96.00 2400 130 220 160 100 100 200 190 200 110 262 4072
85 Primakuin tablet 15 mg TABLET Rp - 0
86 Propanolol HCL tablet 10 mg TABLET Rp 52.00 500 500
87 Propiltiourasil tablet 100 mg TABLET Rp 100.00 70 400 470
88 Ranitidin tablet 150 mg TABLET Rp 105.00 86 100 5200 100 81 120 100 200 100 100 140 200 100 260 150 200 130 70 205 100 7742
89 Salbutamol tablet 2 mg TABLET Rp 66.00 80 3050 48 20 100 150 200 200 50 60 200 100 4258
90 Salbutamol tablet 4 mg TABLET Rp 80.00 100 110 100 70 80 280 20 70 60 16 180 1086
91 Simvastatin 10 mg TABLET Rp 131.00 100 3940 300 248 170 200 240 300 320 150 300 330 250 310 400 480 300 340 150 8828
92 Siprofloksazin tablet 500 mg TABLET Rp 281.00 1480 180 50 110 100 100 150 80 150 100 2500
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
93 Spironolactone 25 mg TABLET Rp 315.00 1000 1000
94 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00 177690 300 70 210 240 35 510 410 600 300 520 300 150 120 420 120 181995
95 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00 80 32 180 292
96 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00 500 104 100 110 814
97 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00 900 140 200 200 200 100 1740
98 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00 10600 100 200 100 200 11200
99 Vitamin B Kompleks TABLET Rp 115.00 150 8300 196 130 200 300 100 260 525 350 400 470 290 200 200 20 500 300 100 12991
100 Zinc 10 mg TABLET Rp 513.00 101 140 1950 150 280 200 100 100 100 140 250 110 160 280 300 260 180 340 300 260 100 5801
b. Injeksi 0
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00 6 28 4 38
2 Amoxillin 1000 mg VIAL Rp 10,500.00 0
3 Ampisillin im/iv 1000mg/ml VIAL Rp - 0
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp - 12 12
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00 2 30 32
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00 8 8
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00 10 10
8 Ceftriaxone 1 gr injeksi VIAL Rp - 12 285 297
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00 10 39 39 10 5 8 6 5 5 9 20 5 13 5 14 5 198
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00 20 20 208 17 17 14 30 10 20 20 17 20 16 20 20 19 10 498
11 Epinefrin injeksi AMPUL Rp 2,204.00 3 9 9 21
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00 7 62 5 8 5 87
13 Fitomenadion (Vit K1)inj infant AMPUL Rp - 3 3
14 Furosemid injeksi AMPUL Rp 2,300.00 3 3
15 Gentamisin injeksi AMPUL Rp 3,386.00 33 4 37
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00 0
17 Kloramfenikol injeksi VIAL Rp - 0
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00 40 688 22 40 35 14 23 5 30 19 37 35 20 21 55 19 10 1113
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00 3 3
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00 1 1
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00 16 73 3 5 5 5 5 112
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00 19 13 520 7 5 564
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp - 0
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp - 3 3
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00 31 5 2 5 3 2 4 52
26 Omeprazole Injeksi AMPUL Rp 11,868.00 23 23
27 Ondansetron injeksi AMPUL Rp 1,650.00 11 135 5 151
28 piracetam injeksi 200mg/5ml BOTOL 7 7
29 Piracetam injeksi 1 gr / 5 ml BOTOL Rp - 21 21
30 Piracetam injeksi 3 gr / 5 ml BOTOL Rp - 0
31 Ranitidin injeksi 50mg/2ml AMPUL Rp 1,458.00 8 20 632 4 10 10 684
32 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00 13 60 73
33 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00 9 20 265 16 10 10 6 20 20 20 25 16 20 10 467
34 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp - 0
35 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00 5 9 14
36 Vitamin B Kompleks injeksi AMPUL Rp - 0
c. Salep 0
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00 48 7 4 5 3 4 5 5 2 4 5 3 3 98
2 Asiklovir krim 5% TUBE Rp 4,000.00 42 5 6 1 3 2 6 2 6 1 2 5 2 5 88
3 Betametason krim 0,1 % TUBE Rp 1,349.00 135 5 11 9 3 10 5 10 3 10 5 12 5 4 5 6 5 243
4 Bufacetin Salep TUBE Rp 3,008.00 319 5 8 5 5 10 5 10 11 13 10 10 5 2 14 10 5 10 5 462
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
5 Gameksan emulsi 1 % 30ml TUBE Rp - 5 5
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00 1 3 4
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00 3 33 12 22 13 8 14 5 13 5 12 19 12 14 15 13 23 11 15 5 267
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00 2 1 2 3 4 2 2 7 23
9 Ketokonazol krim 2% TUBE Rp - 0
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00 2 2 4
11 Miconazol cream 2 % TUBE Rp 3,000.00 245 3 2 4 3 3 3 3 2 5 5 278
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00 8 5 4 17
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00 58 7 5 7 10 7 3 7 3 12 5 124
14 Sulfadiazin Salep TUBE Rp 20,700.00 27 3 3 7 7 10 2 10 6 5 9 89
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00 89 3 5 3 4 9 2 7 8 5 8 2 5 150
16 SYNARCUS TUBE 80 80
d. Serbuk 0
1 Garam oralit untuk 200 ml air SACHET Rp 288.00 36 60 67 120 110 393
2 Salisil Bedak 2 % POT Rp 1,025.00 30 7 7 1 5 5 2 5 2 4 1 3 1 6 79
e. Sirup 0
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00 431 5 29 13 4 40 5 10 15 25 30 42 25 12 8 8 16 15 10 743
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00 10 191 6 5 5 10 5 5 5 5 5 5 5 6 6 5 5 5 289
3 Cetirizin Syr BOTOL Rp - 3 2 2 2 5 2 16
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp - 0
5 Eritromisin sirup BOTOL Rp 6,150.00 8 30 4 10 10 3 65
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00 27 37 25 25 32 20 25 20 25 22 35 27 33 30 28 20 38 20 489
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00 85 7 8 8 9 7 20 12 14 8 8 5 191

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00 8 210 30 11 5 33 9 15 20 10 20 17 10 17 8 13 10 446
9
Mebendazol sirup 100 mg/5ml BOTOL Rp - 0
10
Metronidazole Sirup BOTOL Rp 9,950.00 4 122 126
11
Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00 256 8 5 2 5 5 5 5 291
12
Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00 6 11 7 4 5 3 6 5 8 7 2 64
13
Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00 0
14
Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00 58 58
15
Thiamfenikol syr BOTOL Rp - 8 5 5 18
d. Tetes 0
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00 48 48
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00 35 3 3 7 3 5 5 5 1 2 69
3 Gentian violet larutan 1 % BOTOL Rp - 2 4 2 3 3 1 2 17
4 Karbo Glycerin BOTOL Rp - 0
5 Kloramfenikol tetes mata BOTOL Rp - 25 6 5 10 2 10 58
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00 51 5 2 5 5 2 2 72
7 Polikresulen ( Albothyl ) BOTOL Rp - 2 1 1 1 5
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp - 0
ALKES DAN CAIRAN LUAR 0
1 Alat suntik sekali pakai 1 ml SET Rp 990.00 15 130 625 9 10 30 50 6 220 160 50 44 15 55 63 1482
2 Alat suntik sekali pakai 3 ml SET Rp 792.00 97 120 270 204 20 45 150 120 150 100 126 46 150 100 171 114 100 100 2183
3 Alat suntik sekali pakai 5 ml SET Rp 979.00 5 110 468 36 26 14 30 20 85 32 40 5 20 45 20 956
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00 133 10 3 10 20 10 186
5 Alat suntik sekali pakai 0,5 ml SET 63 63
6 alkacide BOTOL 1 1
7 Alkohol swab PAK Rp 11,000.00 1800 5 1805
8 Aqua pro injeksi, bebas pirogen BOTOL Rp - 10 144 154
9 Aquadest steril BOTOL Rp 14,960.00 1 2 3
10 Blood lancet PCS Rp 14,566.00 300 300
11 Blood Tranfusion set PCS Rp 14,300.00 42 42
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
12 chlorine 1000 ppm BOTOL 7 7
13 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00 19 3 5 1 2 4 2 2 5 2 1 46
14 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00 60 8 1 3 4 2 2 2 82
15 Daryantulle LEMBAR Rp 8,990.00 43 1 1 2 1 48
16 Etanol 70 % BOTOL Rp - 0
17 Etanol 70 % 100 ml BOTOL Rp 2,000.00 168 2 10 5 10 2 5 202
18 Etanol 70 % 1000 ml BOTOL Rp 25,000.00 0
19 Female Catheter no.16 PCS Rp 18,450.00 18 18
20 Female Catheter no.18 PCS Rp 18,450.00 20 20
21 Foley Catheter no.16 PCS Rp 18,450.00 13 13
22 Folley cath no. 18 PCS Rp 18,450.00 1 2 3
22 handrub 500ml BOTOL 9 9
23 handrub refill 5L jerigen 5 5
24 Hanschoen "50 KOTAK Rp 46,200.00 4800 5 116 80 100 2 1 1 100 100 5305
25 Hanschoen steril no 6.5 PCS Rp 9,854.00 155 12 167
26 Hanschoen steril no 7 PCS Rp 9,854.00 16 124 10 18 168
27 Hansaplast 5 cm ROL Rp 25,404.00 0
28 Hansaplast 7,5 cm ROL Rp 31,265.00 0
29 I.V. Catheter No 18 PCS Rp 8,700.00 50 87 2 5 2 146
30 I.V. Catheter No 20 PCS Rp 8,700.00 15 80 5 8 3 1 10 122
31 I.V. Catheter No 22 PCS Rp 8,700.00 17 233 5 1 5 261
32 I.V. Catheter No 24 PCS Rp 8,700.00 10 240 10 1 261
33 I.V. Catheter No 26 PCS Rp 8,700.00 50 50
34 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00 0
35 Infusion set anak PCS Rp 7,000.00 2 271 5 5 283
36 Infusion set dewasa PCS Rp 7,000.00 1 643 2 5 6 5 662
37 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00 6 1 1 1 1 4 1 1 1 1 18
38 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00 362 2 2 8 3 2 3 10 392
39 Kasa Gulung 40 x 80 ROL Rp 149,158.00 3 3
40 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00 3 3
41 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00 16 143 2 5 5 10 4 6 9 5 6 5 216
42 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00 80 2 8 5 2 9 5 111
43 Kasa Steril PAK Rp 7,900.00 1 26 5 1 33
44 Kasa 4m x 5 cm PAK Rp 1,100.00 190 190
45 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00 1 2 3
46 Masker breathing (+ selang) PCS Rp 24,000.00 73 1 74
47 Masker non breathing PCS Rp 21,945.00 2400 50 50 2500
48 Masker N95 PCS Rp 390,000.00 80 80
49 My Jelly 82 gram TUBE Rp 29,550.00 0
50 Nasal kanul S PCS Rp 6,600.00 39 39
51 Nasal kanul L PCS Rp 6,600.00 0
52 NGT 7 x 75/80 PCS Rp - 0
53 Non Woven Fixation 5 cm x 10 m PCS 17 17
54 One Med H2 O2 3 % BOTOL Rp - 0
55 One Med Surgical Blade PCS Rp - 2 180 182
56 Plester 5 yards x 2 inch ROL Rp 18,086.00 1 1
57 Plester infus ( Tegaderm ) PCS Rp 224,200.00 95 2 1 2 100
58 Plester infus (e care + pot) PCS Rp 220,000.00 0
56 plester PCS 17 17
57 Plesterin PCS Rp 30,800.00 0
58 Policlean BOTOL Rp 608,000.00 2 2
59 Polyfix PAK Rp 43,850.00 0
60 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00 0
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
59 Safety box 50 50
60 Spalk SET Rp 61,600.00 13 13
61 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00 15 2 17
62 Tensocrepe PAK Rp 43,897.00 12 12
63 ultrasonic gel 5L jerigen 5 5
64 Urine Bag PCS Rp - 63 63
65 Umbilical Cord "50 PAK Rp 65,000.00 0
66 Underpeds BIJI Rp 1,000.00 150 150
67 Unolab supercare Nitril powder BOX Rp 77,493.00 0
68 Wing Needle No. 18 - 27 SACHET Rp 6,000.00 46 46
69 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00 1 1 1 1 2 1 3 10
70 Yodium Povidon larutan 10 % 60 ml BOTOL Rp - 0
71 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00 1 1 1 1 1 1 1 1 1 9
INFUS 0
1 Asering Larutan infus BOTOL Rp 9,275.00 20 80 100
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00 1 30 20 51
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00 1 40 41
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00 8 2 5 5 4 5 29
5 KAEN 3B BOTOL Rp 10,050.00 140 140
6 KAEN 4B BOTOL Rp 15,730.00 0
7 Metronidazol infus BOTOL Rp 9,950.00 1 2 3
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00 8 22 100 1 6 5 3 2 5 2 2 1 7 2 166
9 Parasetamol Infus BOTOL Rp 12,940.00 20 20
10 Ringer Lactate infus steril BOTOL Rp 7,150.00 10 15 163 2 2 4 2 1 1 9 209
OBAT PATEN 0
1 Aptil BOTOL Rp 23,100.00 2 2
2 Bioplasenton Jelly TUBE Rp 14,175.00 3 2 5 3 5 18
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00 12 12
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00 27 2 29
5 Bufacomb TUBE Rp 3,008.00 1 1 2
6 Calporosis TABLET Rp 430.00 900 900
7 Cendo Lyters tetes mata BOTOL Rp 430.00 0
8 Cendo Xitrol tetes mata BOTOL Rp - 0
9 Chloramex 500 mg KAPSUL Rp - 290 400 690
10 Combivent Nebule BOTOL Rp 4,995.00 90 90
11 Citicholin inj. 250 mg / 2ml AMPUL Rp - 0
12 ETHYLCHLORIDE SPRAY 100ML BOTOL 5 5
13 Hiopar TABLET Rp 1,360.00 0
13 ketoprofen supp 100mg SUPP 17 17
14 Laxadin sirup BOTOL Rp 12,450.00 43 5 48
15 Lactodiar SACHET Rp - 0
16 Lytamin syrup BOTOL Rp 5,000.00 164 3 5 2 2 10 5 191
16 MDT MB ADULT TABLET 6 6
17 Mecobion tablet TABLET Rp 1,000.00 1500 10 1510
18 Metamizole injeksi 500mg AMPUL Rp 8,635.00 501 501
19 Microlax BIJI Rp - 0
20 Neucompli TABLET Rp 5,500.00 11190 100 110 70 110 130 100 100 11910
21 Neurotropik plus TABLET Rp - 0
22 Neurotropik injeksi 5000mcg AMPUL Rp 362.00 9 155 164
23 Novalgin/Antrain injeksi AMPUL Rp 3,575.00 29 12 41
24 Noza TABLET Rp 11,500.00 0
25 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00 159 10 17 16 14 23 10 10 16 15 12 10 15 10 20 16 10 15 10 408
26 Pantocain Tetes Mata BOTOL Rp 11,500.00 10 10
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
27 Parasetamol supp BIJI Rp 1,500.00 0
28 Pehacain injeksi AMPUL Rp 12,155.00 400 400
29 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00 57 3 60
30 Salbutamol rotacaps KAPSUL Rp 450.00 0
31 Salbutamol rotahaler PCS Rp - 0
32 Sotatic Inj AMPUL Rp 1,650.00 0
33 Spasminal/Scopma TABLET Rp 1,360.00 100 100 200
34 Puralex TABLET Rp 140.00 10 1150 40 40 100 100 100 100 120 140 330 50 100 100 100 2580
35 Ulsidex TABLET Rp 424.00 900 900
36 Ventolin nebulizer BOTOL Rp 4,000.00 3 42 3 48
37 Zirkum syr BOTOL Rp 14,980.00 2 5 2 3 5 17
OBAT KHUSUS 0
f. Gizi 0
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00 7 7
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00 85 85
3 Mineral Mix PAKET 440 440
g. Jiwa 0
1 Amitriptyllin 25 mg TABLET Rp 143.00 300 300
2 Clobazam 10mg tab TABLET Rp 967.00 0
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp - 0
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00 0
5 Fenitoin Natrium 30 mg KAPSUL Rp - 0
6 Haldol decanoat 50mg/ml inj AMPUL Rp - 5 5
7 Haloperidol 1,5 mg TABLET Rp 66.00 0
8 Haloperidol 5mg TABLET Rp 69.00 700 700
9 Karbamazepin 200 mg TABLET Rp 228.00 0
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp - 0
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp - 0
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00 200 200
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp - 0
14 Lodomer 5mg/ml inj AMPUL Rp - 0
15 Risperidone 2mg TABLET Rp 347.00 0
16 Sikzonoat 25mg/ml inj AMPUL Rp - 0
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00 0
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00 1000 1000
k. Psikotropik & Narkotik 0
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00 25 25
2 Diazepam 2 mg TABLET Rp 45.00 0
3 Diazepam 5 mg TABLET Rp 80.00 100 100
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp - 0
5 Fenobarbital 30 mg TABLET Rp - 95 95
6 Kodein tablet 10mg TABLET Rp 550.00 0
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00 8 8
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00 9 9
9 Valdimex Inj AMPUL Rp 12,100.00 0
m. Serum 0
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00 0
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp - 0
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00 0
n. TB Paru 0
1 Isoniazid (INH) 100mg TABLET 0
2 Kombipack Kategori 1 PAKET Rp - 0
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00 1 1
 PONKESD
POS POS ES
SENGKRA SUMBER PONKES PUSTU SUMBER KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD SB.NGEP
NO NAMA OBAT SATUAN harga satuan RANAP UGD INDUK PILANG BEDALI
KAN
KALIREJO TURIREJO LAWANG
NGEPOH MULYO MULYO PORONG N N JO JO UR G I OH TOTAL
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00 0
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00 0
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00 11 11
7 Obat Antituberkulosis Sisipan PAKET Rp - 0
8 Slide PAK 0
9 Slide box BOX Rp - 0
10 Sputum pot BIJI Rp 2,728.00 0
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp - 0
12 Ziehl nelseen PAKET Rp 276,600.00 0

Mengetahui Yang Menyerahkan Yang meminta/melapor

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi Kepala Puskesmas
dan Pengawasan Farmasi

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
DINAS KESEHATAN KABUPATEN MALANG
PROPINSI JAWA TIMUR

UNIT : PUSKESMAS LAWANG

NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT GENERIK
a. Tablet/Kapsul
1 Acarbose 100 mg TABLET Rp 908.00
2 Adalat Oros 20 mg TABLET Rp 3,255.00
3 Albendazol 400 mg TABLET Rp -
4 Alopurinol 100 mg TABLET Rp 90.00
5 Alopurinol 300 mg TABLET Rp 210.00
6 Ambroxol 30 mg TABLET Rp 100.00
7 Amlodipin 5 mg TABLET Rp 105.00
8 Amlodipin 10 mg TABLET Rp 104.00
9 Aminofilina 200 mg TABLET Rp 91.00
10 Amoksilin 250 mg KAPSUL Rp 195.00
11 Amoksilin 500 mg KAPLET Rp 232.00
12 Antalgin 500 mg TABLET Rp -
13 Antasida (MgOH 200mg+AlOH 200mg) TABLET Rp 62.00
14 Anti Hemoroid (Bismut TABLET
subgallat150mg+Heksaklorofen2,5mg) Rp 3,045.00
15 Antimigran (Ergotamin Tartrat 1mg + Kofein 50mg) TABLET Rp 100.00
16 Asam Askorbat ( Vit C ) 50 mg TABLET Rp 104.00
17 Asam Askorbat (Vit C) 250 mg TABLET Rp 125.00
18 Asam folat 1 mg TABLET Rp 67.00
19 Asam mefenamat 500mg TABLET Rp 106.00
20 Asetosal 100 mg TABLET Rp 130.00
21 Asiklovir 400mg TABLET Rp 349.00
22 Betahistin mesilat 5 mg TABLET Rp 149.00
23 Bisoprolol tablet 5 mg TABLET Rp 330.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Bromhexin 8 mg TABLET
25 Cefadroxil 500 mg KAPSUL Rp 516.00
26 Cetirizin 10mg TABLET Rp 143.00
27 Deksametason 0,5 mg TABLET Rp 44.00
28 Dekstrometorfan 15 mg TABLET Rp -
29 Digoksin 0,25 mg TABLET Rp 105.00
30 Diltiazem 30 mg TABLET Rp 127.00
31 Dimenhidrinat tablet 50mg TABLET Rp 99.00
32 Doksisiklin 100mg KAPSUL Rp 268.00
33 Domperidon tablet 10 mg TABLET Rp 118.00
34 Efedrin HCL 25 mg TABLET Rp 47.00
35 Eritromisin 500mg KAPLET Rp 730.00
36 Fitomenadion (Vit K1) 10mg TABLET Rp 691.00
37 Furosemid 40 mg TABLET Rp 78.00
38 Glibenklamid 5 mg TABLET Rp 100.00
39 Glimepiride tablet 2 mg TABLET Rp 289.00
40 Gliseril Guaiakolat 100 mg TABLET Rp -
41 Griseofulvin 125 mg TABLET Rp 245.00
42 Hidroklorotiazid (HCT) 25 mg TABLET Rp 149.00
43 Hyosin N Butilbromida 10mg TABLET Rp 300.00
44 Ibuprofen 400 mg TABLET Rp 127.00
45 Ibuprofen 200 mg TABLET Rp 105.00
46 Isosorbid Dinitrat sublingual 5 mg TABLET Rp 88.00
47 Kalium Diklofenac 50mg TABLET Rp 200.00
48 Kalsium Laktat (Kalk) 500 mg TABLET Rp 63.00
49 Kaptopril 25 mg TABLET Rp 80.00
50 Kaptopril 12,5 mg TABLET Rp 62.00
51 Ketokonazol 200mg tablet TABLET Rp 280.00
52 Klindamisin kapsul 300 mg KAPSUL Rp 361.00
53 Klopidogrel TABLET Rp 2,000.00
54 Kloramfenikol kapsul 250 mg KAPSUL Rp 249.00
55 Klorfeniramin Maleat (CTM) 4 mg TABLET Rp 36.00
56 Klorokuin tablet 150 mg TABLET Rp -
57 Klorpropamid tablet 100 mg TABLET Rp -
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO

58 Kotrimoksazol anak TABLET

(Sulfametoksazol100mg+Trimetoprim20mg) Rp -

59 Kotrimoksazol dewasa kombinasi : TABLET

Sulfametoksazol400mg+Trimetoprim80mg Rp 151.00
60 Levofloksasin 500 mg TABLET Rp 495.00
61 Lisinopril 5mg tablet TABLET Rp 269.00
62 Loratadin tablet 10 mg TABLET Rp 134.00
63 Mebendazol tablet 100 mg TABLET Rp -
64 Meloksikam tablet 7,5 mg TABLET Rp 629.00
65 Metformin 500mg tablet TABLET Rp 100.00
66 Metil Prednisolon 4 mg TABLET Rp 194.00
67 Metilergometrin Maleat 0,125 mg TABLET Rp 154.00
68 Metoklopramid 5mg TABLET Rp 123.00
69 Metronidazol 250 mg TABLET Rp 78.00
70 Metronidazol 500mg TABLET Rp 133.00
71 N - Asetylsistein KAPSUL Rp 1,100.00
72 Natrium Diklofenac 25 mg TABLET Rp 132.00
73 Natrium Diklofenac 50 mg TABLET Rp 159.00
74 Nifedipin 10 mg tablet TABLET Rp 104.00
75 Nistatin tablet vaginal 100.000 IU/g TABLET Rp 545.00
76 Omeprazole 20mg TABLET Rp 160.00
77 Ondansetron tab TABLET Rp 160.00
78 Parasetamol 100 mg TABLET Rp 200.00
79 Parasetamol 500 mg TABLET Rp 56.00
80 Pirantel 125 mg TABLET Rp 269.00
81 Pirasetam 800 mg tablet TABLET Rp 62.00
82 Piridoksin HCL (Vit B6) tablet 10 mg TABLET Rp 118.00
83 Prednison tablet 5 mg TABLET Rp 96.00
84 Primakuin tablet 15 mg TABLET Rp -
85 Propanolol HCL tablet 10 mg TABLET Rp 52.00
86 Propiltiourasil tablet 100 mg TABLET Rp 100.00
87 Ranitidin tablet 150 mg TABLET Rp 105.00
88 Salbutamol tablet 2 mg TABLET Rp 66.00
89 Salbutamol tablet 4 mg TABLET Rp 80.00
90 Simvastatin 10 mg TABLET Rp 131.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
91 Siprofloksazin tablet 500 mg TABLET Rp 281.00
92 Spironolactone 25 mg TABLET Rp 315.00
93 Tablet Tambah Darah Kombinasi : Besi sulfat TABLET
200mg+Asam folat 0,25mg Rp 355.00
94 Tetrasiklin HCL kapsul 250 mg KAPSUL Rp 163.00
95 Tetrasiklin HCL kapsul 500 mg KAPSUL Rp 310.00
96 Thiamfenikol 500mg kapsul KAPSUL Rp 1,000.00
97 Tiamin HCL (VitB1) 50 mg TABLET Rp 86.00
98 Vitamin B Kompleks TABLET Rp 115.00
99 Zinc 10 mg TABLET Rp 513.00
b. Injeksi
1 Aminofilina 24 mg/ml - 10 ml AMPUL Rp 2,998.00
2 Amoxillin 1000 mg VIAL Rp 10,500.00
3 Ampisillin im/iv 1000mg/ml VIAL Rp -
4 Antalgin 250 mg/ml - 2 ml AMPUL Rp -
5 Asam Tranexamat Injeksi AMPUL Rp 1,956.00
6 Atropin sulfat 0,25mg/ml-1 ml AMPUL Rp 1,672.00
7 Calsium Gluconas injeksi 10 % BOTOL Rp 9,955.00
8 Ceftriaxone 1 gr injeksi VIAL Rp -
9 Deksametason injeksi 5 mg/ml-1ml AMPUL Rp 1,518.00
10 Difenhidramin HCL Inj 10mg/ml-1 ml AMPUL Rp 1,175.00
11 Epinefrin injeksi AMPUL Rp 2,204.00
12 Fitomenadion (Vit K1)inj 10mg/ml-1ml AMPUL Rp 3,550.00
13 Fitomenadion (Vit K1)inj infant AMPUL Rp -
14 Furosemid injeksi AMPUL Rp 2,300.00
15 Gentamisin injeksi AMPUL Rp 3,386.00
16 Hyosin n butilbromid inj 250mg/ml AMPUL Rp 4,500.00
17 Kloramfenikol injeksi VIAL Rp -
18 Lidokain komp injeksi,Kombinasi:Lidokain HCl2% AMPUL
+Epinefrin1:80000-2ml Rp 1,937.00
19 Magnesium sulfat injeksi (IV) 20 % - 25 ml BOTOL Rp 3,200.00
20 Magnesium sulfat injeksi (IV) 40 % - 25 ml BOTOL Rp 3,650.00
21 Metilergometrin Maleat inj. 0,200mg-1ml AMPUL Rp 2,684.00
22 Metoklopramid inj. 5mg / ml AMPUL Rp 3,395.00
23 Natrium Tiosulfat injeksi 25 % - 10 ml BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
24 Oksitetrasiklin HCL inj. i.m 50mg/ml-10ml AMPUL Rp -
25 Oksitosin injeksi 10 IU/ml - 1 ml AMPUL Rp 1,900.00
26 Omeprazole Injeksi AMPUL Rp 11,868.00
27 Ondansetron injeksi AMPUL Rp 1,650.00
28 Piracetam injeksi 1 gr / 5 ml BOTOL Rp -
29 Piracetam injeksi 3 gr / 5 ml BOTOL Rp -
30 Ranitidin injeksi 25mg/2ml AMPUL Rp 1,458.00
31 Sefotaksim injeksi 1 gram VIAL Rp 4,898.00
32 Sianokobalamin(VitB12)inj.500mcg/ml-1ml AMPUL Rp 1,098.00
33 Streptomisin serbuk injeksi iv 1000mg/ml VIAL Rp -
34 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ml AMPUL Rp 1,100.00
35 Vitamin B Kompleks injeksi AMPUL Rp -
c. Salep
1 Antifungi (As. Benzoat6%+As. salisilat 3%) POT Rp 4,323.00
2 Asiklovir krim 5% TUBE Rp 4,000.00
3 Betametason krim 0,1 % TUBE Rp 1,349.00
4 Bufacetin Salep TUBE Rp 3,008.00
5 Gameksan emulsi 1 % 30ml TUBE Rp -
6 Gentamisin salep kulit 0.1%-5gr TUBE Rp 3,000.00
7 Gentamisin salep mata 0,3% TUBE Rp 2,000.00
8 Hidrokortison krim 2,5 % TUBE Rp 2,650.00
9 Ketokonazol krim 2% TUBE Rp -
10 Kloramfenikol salep mata 1 % TUBE Rp 1,810.00
11 Miconazol cream 2 % TUBE Rp 3,000.00
12 Oksitetrasiklin HCL 1 % salep mata TUBE Rp 2,000.00
13 Oksitetrasiklin HCL salep 3 % TUBE Rp 2,500.00
14 Sulfadiazin Salep TUBE Rp 20,700.00
15 Salep 2-4 Komb: As salisilat2%+Belerang endap4% POT Rp 2,429.00
d. Serbuk
1 Garam oralit untuk 200 ml air SACHET Rp 288.00
2 Salisil Bedak 2 % POT Rp 1,025.00
e. Sirup
1 Amoksilin 125mg/5ml VIAL Rp 1,881.00
2 Antasida syr (MgOH 200mg/5ml+AlOH 200mg/5ml) BOTOL Rp 1,923.00
3 Cetirizin Syr BOTOL Rp -
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
4 Dekstrometorfan 10 mg / 5 ml BOTOL Rp -
5 Eritromisin sirup BOTOL Rp 6,150.00
6 Ibuprofen suspensi 100mg/5ml BOTOL Rp 4,499.00
7 Kloramfenikol suspensi 125mg/5ml BOTOL Rp 4,700.00

8 Kotrimoksazol Suspensi komb: Sulfametoksazol BOTOL

200mg+Trimetoprim40mg/5ml Rp 2,286.00
9 Mebendazol sirup 100 mg/5ml BOTOL Rp -
10 Metronidazole Sirup BOTOL Rp 9,950.00
11 Obat Batuk Hitam ( O B H ) cairan BOTOL Rp 4,840.00
12 Parasetamol sirup 120mg/5ml BOTOL Rp 1,010.00
13 Parasetamol drop 100mg/ml btl @ 15ml BOTOL Rp 5,200.00
14 Sefadroxil 125 mg/5 ml BOTOL Rp 3,980.00
15 Thiamfenikol syr BOTOL Rp -
d. Tetes
1 Fenol Gliserol tetes telinga 10 % BOTOL Rp 2,500.00
2 Gentamisin tetes mata 0.3% BOTOL Rp 4,170.00
3 Gentian violet larutan 1 % BOTOL Rp -
4 Karbo Glycerin BOTOL Rp -
5 Kloramfenikol tetes mata BOTOL Rp -
6 Kloramfenikol tetes telinga 3 % BOTOL Rp 1,540.00
7 Polikresulen ( Albothyl ) BOTOL Rp -
8 Sulfasetamid Natrium tetes mata 15 % BOTOL Rp -
ALKES DAN CAIRAN LUAR
1 Alat suntik sekali pakai 1 ml SET Rp 990.00
2 Alat suntik sekali pakai 3 ml SET Rp 792.00
3 Alat suntik sekali pakai 5 ml SET Rp 979.00
4 Alat suntik sekali pakai 10 ml SET Rp 1,298.00
5 Alkohol swab PAK Rp 11,000.00
6 Aqua pro injeksi, bebas pirogen BOTOL Rp -
7 Aquadest steril BOTOL Rp 14,960.00
8 Blood lancet PCS Rp 14,566.00
9 Blood Tranfusion set PCS Rp 14,300.00
10 Catgut chromic/benang bedah No. 2/0-3/0 SACHET Rp 34,170.00
11 Catgut plain/benang bedah No. 2/0-3/0 SACHET Rp 35,740.00
12 Daryantulle LEMBAR Rp 8,990.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
13 Etanol 70 % BOTOL Rp -
14 Etanol 70 % 100 ml BOTOL Rp 2,000.00
15 Etanol 70 % 1000 ml BOTOL Rp 25,000.00
16 Female Catheter no.16 PCS Rp 18,450.00
17 Female Catheter no.18 PCS Rp 18,450.00
18 Foley Catheter no.16 PCS Rp 18,450.00
19 Folley cath no. 18 PCS Rp 18,450.00
20 Hanschoen "50 KOTAK Rp 46,200.00
21 Hanschoen steril no 6.5 PCS Rp 9,854.00
22 Hanschoen steril no 7 PCS Rp 9,854.00
23 Hansaplast 5 cm ROL Rp 25,404.00
24 Hansaplast 7,5 cm ROL Rp 31,265.00
25 I.V. Catheter No 18 PCS Rp 8,700.00
26 I.V. Catheter No 20 PCS Rp 8,700.00
27 I.V. Catheter No 22 PCS Rp 8,700.00
28 I.V. Catheter No 24 PCS Rp 8,700.00
29 I.V. Catheter No 26 PCS Rp 8,700.00
30 I.V. Catheter No 26 with wings & port PCS Rp 8,700.00
31 Infusion set anak PCS Rp 7,000.00
32 Infusion set dewasa PCS Rp 7,000.00
33 Kapas Pembalut / Absorben 250 gr ROL Rp 28,530.00
34 Kasa Pembalut 2 m x 80 cm ROL Rp 9,400.00
35 Kasa Gulung 40 x 80 ROL Rp 149,158.00
36 Kasa Pembalut elastic 3 inchi ROL Rp 8,000.00
37 Kasa Pembalut Hidrofil 4 m x 15 cm ROL Rp 3,800.00
38 Kasa Pembalut Hidrofil 4 m x 3 cm ROL Rp 800.00
39 Kasa Steril PAK Rp 7,900.00
40 Kasa 4m x 5 cm PAK Rp 1,100.00
41 Lisol, mengandung Kresol tersabun 50% BOTOL Rp 41,000.00
42 Masker breathing (+ selang) PCS Rp 24,000.00
43 Masker non breathing PCS Rp 21,945.00
44 Masker N95 PCS Rp 390,000.00
45 My Jelly 82 gram TUBE Rp 29,550.00
46 Nasal kanul S PCS Rp 6,600.00
47 Nasal kanul L PCS Rp 6,600.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
48 NGT 7 x 75/80 PCS Rp -
49 Non Woven Fixation 5 cm x 10 m PCS
50 One Med H2 O2 3 % BOTOL Rp -
51 One Med Surgical Blade PCS Rp -
52 Plester 5 yards x 2 inch ROL Rp 18,086.00
53 Plester infus ( Tegaderm ) PCS Rp 224,200.00
54 Plester infus (e care + pot) PCS Rp 220,000.00
55 Plesterin PCS Rp 30,800.00
56 Policlean BOTOL Rp 608,000.00
57 Polyfix PAK Rp 43,850.00
58 Rivanol larutan 0,1 % 300ml BOTOL Rp 1,000.00
59 Spalk SET Rp 61,600.00
60 Silk ( Benang Bedah Sutera ) No. 3/0 SACHET Rp 35,740.00
61 Tensocrepe PAK Rp 43,897.00
62 Urine Bag PCS Rp -
63 Umbilical Cord "50 PAK Rp 65,000.00
64 Underpeds BIJI Rp 1,000.00
65 Unolab supercare Nitril powder BOX Rp 77,493.00
66 Wing Needle No. 18 - 27 SACHET Rp 6,000.00
67 Yodium Povidon larutan 10 % 30 ml BOTOL Rp 2,900.00
68 Yodium Povidon larutan 10 % 60 ml BOTOL Rp -
69 Yodium Povidon larutan 10 % 300 ml BOTOL Rp 18,000.00
INFUS
1 Asering Larutan infus BOTOL Rp 9,275.00
2 Glukosa larutan infus 10 % steril BOTOL Rp 6,900.00
3 Glukosa larutan infus 40 % steril BOTOL Rp 7,000.00
4 Glukosa larutan infus 5 % steril BOTOL Rp 6,900.00
5 KAEN 3B BOTOL Rp 10,050.00
6 KAEN 4B BOTOL Rp 15,730.00
7 Metronidazol infus BOTOL Rp 9,950.00
8 Natrium Klorida larutan infus 0,9 % steril BOTOL Rp 6,410.00
9 Parasetamol Infus BOTOL Rp 12,940.00
10 Ringer Lactate infus steril BOTOL Rp 7,150.00
OBAT PATEN
1 Aptil BOTOL Rp 23,100.00
NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
2 Bioplasenton Jelly TUBE Rp 14,175.00
3 Bisakodil suppositoria 5mg TUBE Rp 5,800.00
4 Bisakodil suppositoria 10mg BIJI Rp 15,000.00
5 Bufacomb TUBE Rp 3,008.00
6 Calporosis TABLET Rp 430.00
7 Cendo Lyters tetes mata BOTOL Rp 430.00
8 Cendo Xitrol tetes mata BOTOL Rp -
9 Chloramex 500 mg KAPSUL Rp -
10 Combivent Nebule BOTOL Rp 4,995.00
11 Citicholin inj. 250 mg / 2ml AMPUL Rp -
12 Hiopar TABLET Rp 1,360.00
13 Laxadin sirup BOTOL Rp 12,450.00
14 Lactodiar SACHET Rp -
15 Lytamin syrup BOTOL Rp 5,000.00
16 Mecobion tablet TABLET Rp 1,000.00
17 Metamizole injeksi 500mg AMPUL Rp 8,635.00
18 Microlax BIJI Rp -
19 Neucompli TABLET Rp 5,500.00
20 Neurotropik plus TABLET Rp -
21 Neurotropik injeksi 5000mcg AMPUL Rp 362.00
22 Novalgin/Antrain injeksi AMPUL Rp 3,575.00
23 Noza TABLET Rp 11,500.00
24 Obat Batuk Anak sirup (Babys Cough ) BOTOL Rp 3,575.00
25 Pantocain Tetes Mata BOTOL Rp 11,500.00
26 Parasetamol supp BIJI Rp 1,500.00
27 Pehacain injeksi AMPUL Rp 12,155.00
28 Permetrin/Scabicid krim 5% TUBE Rp 6,600.00
29 Salbutamol rotacaps KAPSUL Rp 450.00
30 Salbutamol rotahaler PCS Rp -
31 Sotatic Inj AMPUL Rp 1,650.00
32 Spasminal/Scopma TABLET Rp 1,360.00
33 Puralex TABLET Rp 140.00
34 Ulsidex TABLET Rp 424.00
35 Ventolin nebulizer BOTOL Rp 4,000.00
36 Zirkum syr BOTOL Rp 14,980.00
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
OBAT KHUSUS
f. Gizi
1 Retinol ( Vit A ) kapsul 100.000 IU KAPSUL Rp 284.00
2 Retinol ( Vit A ) kapsul 200.000 IU KAPSUL Rp 459.00
3 Mineral Mix PAKET
g. Jiwa
1 Amitriptyllin 25 mg TABLET Rp 143.00
2 Clobazam 10mg tab TABLET Rp 967.00
3 Fenitoin Natrium inj. 50 mg/ml AMPUL Rp -
4 Fenitoin Natrium 100 mg KAPSUL Rp 154.00
5 Fenitoin Natrium 30 mg KAPSUL Rp -
6 Haldol decanoat 50mg/ml inj AMPUL Rp -
7 Haloperidol 1,5 mg TABLET Rp 66.00
8 Haloperidol 5mg TABLET Rp 69.00
9 Karbamazepin 200 mg TABLET Rp 228.00
10 Klorpromazin HCL injeksi 25 mg/ml - 1 ml AMPUL Rp -
11 Klorpromazin HCL injeksi 5 mg/ml - 2 ml AMPUL Rp -
12 Klorpromazin HCL tablet salut 100 mg TABLET Rp 144.00
13 Klorpromazin HCL tablet salut 25 mg TABLET Rp -
14 Lodomer 5mg/ml inj AMPUL Rp -
15 Risperidone 2mg TABLET Rp 347.00
16 Sikzonoat 25mg/ml inj AMPUL Rp -
17 Trifluoperazin tablet 5 mg TABLET Rp 296.00
18 Triheksifenidil Hidroklorida tab 2 mg TABLET Rp 80.00
k. Psikotropik & Narkotik
1 Diazepam injeksi 5 mg/ml - 2 ml AMPUL Rp 4,180.00
2 Diazepam 2 mg TABLET Rp 45.00
3 Diazepam 5 mg TABLET Rp 80.00
4 Fenobarbital injeksi 50 mg / ml - 2 ml AMPUL Rp -
5 Fenobarbital 30 mg TABLET Rp -
6 Kodein tablet 10mg TABLET Rp 550.00
7 Stesolid rectal supp 5 mg BIJI Rp 11,517.00
8 Stesolid rectal supp 10 mg BIJI Rp 16,742.00
9 Valdimex Inj AMPUL Rp 12,100.00
m. Serum
 NO NAMA OBAT SATUAN harga satuan PILANG BEDALI SENGKRA SUMBER PONKES
RANAP UGD INDUK KAN KALIREJO NGEPOH MULYO
1 Serum Anti Bisa Ular Polivalen inj.5 ml(ABUI) VIAL Rp 462,000.00
2 Serum Anti Difteri inj. 20.000 IU/vial (ADS) VIAL Rp -
3 Serum Anti Tetanus inj. 1.500 IU/ampul (ATS) VIAL Rp 170,000.00
n. TB Paru
1 Isoniazid (INH) 100mg TABLET
2 Kombipack Kategori 1 PAKET Rp -
3 Obat Antituberkulosis Anak PAKET Rp 214,900.00
4 Obat Antituberkulosis kategori 2 ( FDC ) PAKET Rp 1,199,990.00
5 Obat Antituberkulosis kategori 3 (FDC) PAKET Rp 154,000.00
6 Obat Antituberkulosis kategori I ( FDC ) PAKET Rp 359,990.00
7 Obat Antituberkulosis Sisipan PAKET Rp -
8 Slide PAK
9 Slide box BOX Rp -
10 Sputum pot BIJI Rp 2,728.00
11 Streptomycin inj./iv 1500 mg/ml VIAL Rp -
12 Ziehl nelseen PAKET Rp 276,600.00

Mengetahui Yang Menyerahkan

Kepala Seksi Pengelolaan Obat Petugas Perbekalan Farmasi
dan Pengawasan Farmasi
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
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PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL
 POS POS
PUSTU SUMBER TURIREJO LAWANG KETINDA KETINDA WONORE WONORE SIDOLUH SRIGADIN SIDODAD
MULYO PORONG N N JO JO UR G I TOTAL

Yang meminta/melapor
Kepala Puskesmas

dr.Nur Syamsu Dhuha

NIP.19771202 201001 1 002