PT.

ASURANSI JIWA INHEALTH INDONESIA

REKAPITULASI PENGAJUAN TAGIHAN
NAMA PROVIDER : IF RS JIH (1202A001)

TINGKAT PELAYANAN : OBAT RJTL

TANGGAL PELAYANAN : 21-Nov-2019 s.d 30-Nov-2019

NO TGL PELAYANAN NORESEP NOKA PESERTA NAMA PESERTA R/NR NAMA OBAT JUMLAH HARGA HARGA
1 21 Nov 2019 614 1041014351169 ANDREAS GE RELOVEIN N [FOI] Cefixime Trihydrate HEXP sir kering 100 mg/5 1.00 14,560 31,816
NUGROHO ml btl 30 ml
N [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

N [STFOI] Paracetamol BERN sir 120 mg/5 ml btl 60 ml 1.00 5,200

(Dengan Harga)
R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 5.00 720

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731

(Dengan Harga)
2 21 Nov 2019 608 1001493380248 MARDIAN SEKAR NINGSIH N [FOI] Obimin AF DAVA tab Komb 30.00 40,000 107,972

N [FOI] Cavit D3 MERC tab komb 30.00 67,972

3 21 Nov 2019 585 1011499823946 WULAN SARI N [FOI] Aspilets Chewable DAVA tab 80 mg 20.00 10,960 37,760

N [FOI] Obimin AF DAVA tab Komb 20.00 26,800

4 21 Nov 2019 592 1001424959515 ADITYA JOKO PAMBAYUN N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 10.00 9,988 9,988
Harga)
5 21 Nov 2019 593 1001438930777 MELISSA RAISHA JASMINE N [FOI] Cavit D3 MERC tab komb 10.00 22,924 22,924

6 21 Nov 2019 590 1051493379693 FLO DEALMOND RAMADHANI N [FOI] Cefixime Trihydrate HEXP sir kering 100 mg/5 1.00 14,560 26,672
CHOANDRA ml btl 30 ml
R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 4.00 576

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731

(Dengan Harga)
8 21 Nov 2019 612 1001463696123 ALI ARDI, S.SOS N [FOI] Lipitor PFIZ tab 20 mg 30.00 189,400 197,360

N [STFOI] Gramasal GRAF tab 100 mg (Dengan Harga) 30.00 7,960

9 21 Nov 2019 594 1001545475815 H. MARDJONO N [FOI] Canderin 16 mg DEXA tab 16 mg 30.00 267,700 620,000

N [STFOI] Levemir NOVO Prefilled inj 100 IU/ml 2.00 352,300

flexpen 3 ml (Dengan Harga)
10 21 Nov 2019 586 1001005050341 DRG. SUHARDI N [FOI] Norvask PFIZ tab 5 mg 30.00 77,800 165,320

N [STFOI] Valsartan 80 mg NOVE tab 80 mg (Dengan 30.00 87,520

Harga)
11 21 Nov 2019 587 1011005050342 HARMI RUNTUNI N [FOI] Norvask PFIZ tab 5 mg 30.00 77,800 382,440

N [FOI] Aspilets Chewable DAVA tab 80 mg 30.00 16,240

N [FOI] Crestor 20 mg ASCA tab 20 mg 30.00 288,400

12 21 Nov 2019 600 1001440186176 SRI WIDYOWATI.SE N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 6.00 2,560 2,560
Harga)
13 21 Nov 2019 598 1001489637532 AGUS SUMITRO N [FOI] Urdahex DANK kaps 250 mg 30.00 172,012 579,212

N [STFOI] Harnal Ocas ASTE tab lepas lambat 0,4 mg 30.00 407,200
(Dengan Harga)
14 21 Nov 2019 602 1001012358025 RATIH PRIMA MARTA H N [STFOI] Paracetamol BERN tab 500 mg (Dengan 14.00 2,584 2,584
Harga)
15 21 Nov 2019 607 1041550574174 CAESARANI ANGEL CHARMANITY N [FOI] Singulair TMIN tab 10 mg 30.00 240,232 240,232

16 21 Nov 2019 604 1011565075162 AINI SHOFIA, SH N [STFOI] Anelat IFAR kapl 1 mg (Dengan Harga) 7.00 1,584 69,378

N [STFOI] Donepezil 5 mg NOVE tab 5 mg (Dengan 7.00 50,296

Harga)
R.1 [STFOI] Paracetamol BERN tab 500 mg (Dengan 15.00 2,340
Harga)
R.1 [STFOI] Natrium Diklofenak BERN tab 50 mg 6.00 1,152
(Dengan Harga)
R.2 [FOI] Gabapentin 300 mg NOVE kaps 300 mg 4.00 12,806

17 21 Nov 2019 603 1001565075161 ARMY LUBIS, SE N [FOI] Atorvastatin 20 mg NOVE tab 20 mg 14.00 40,720 44,969

N [STFOI] Diazepam KIFA tab 2 mg (Dengan Harga) 6.00 1,293

R.1 [STFOI] Paracetamol BERN tab 500 mg (Dengan 9.00 1,404

Harga)
R.1 [STFOI] Natrium Diklofenak BERN tab 50 mg 6.00 1,152
(Dengan Harga)
18 21 Nov 2019 606 1001545475815 H. MARDJONO N [FOI] Lyrica PFIZ kaps 50 mg 60.00 446,800 1,264,546

N [FOI] Clopidogrel Bisulfate HEXP kapl salut selaput 30.00 108,328

75 mg
N [FOI] Amlodipin Besylat LAND tab 5 mg 30.00 6,880

N [STFOI] Provelyn 75 KALB kaps 75 mg (Dengan 60.00 500,800

Harga)
N [STFOI] Alprazolam 0,5 mg OTTO tab 0,5 mg 5.00 3,040
(Dengan Harga)
N [STFOI] Candesartan 16 mg NOVE tab 16 mg 30.00 154,840
(Dengan Harga)
N [STFOI] Omeprazole HEXP kaps 20 mg (Dengan 60.00 21,784
Harga)
R.1 [STFOI] Paracetamol BERN tab 500 mg (Dengan 108.00 16,848
Harga)
R.1 [STFOI] Tramadol INFA kaps 50 mg (Dengan 15.00 4,626
Harga)
19 22 Nov 2019 825 1001008106054 ZUAMAH N [STFOI] Provera 10 mg PFIZ tab 10 mg (Dengan 14.00 144,880 144,880
Harga)
20 22 Nov 2019 621 1051546252059 HAFIZA ZULFA ZEINITA N [FOI] Lansoprazole 30 mg NOVE kaps 30 mg 20.00 13,864 26,388

N [STFOI] Paracetamol BERN tab 500 mg (Dengan 10.00 1,960

Harga)
N [STFOI] Ondansetron 4 mg NOVE tab 4 mg 10.00 10,564
(Dengan Harga)
21 22 Nov 2019 615 1011424961529 NUR FADHILLAH N [FOI] Aspilets Chewable DAVA tab 80 mg 30.00 16,240 84,212

N [FOI] Cavit D3 MERC tab komb 30.00 67,972

22 22 Nov 2019 641 1051011700874 AGHA AHNAF ARRAYYAN N [FOI] Pamol supp 125 mg INTR supp 125 mg 1.00 8,200 8,200

23 22 Nov 2019 634 1001464169411 KARIMA NURBAITI N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 10.00 9,988 9,988
Harga)

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 24 22 Nov 2019 638 1041008049281 ZIDNI HADZIQ ALFARABI N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 20.00 6,000 31,600
Harga)
N [STFOI] Meptin Mini OTSU tab 25 mcg (Dengan 10.00 25,600
Harga)
25 22 Nov 2019 640 1051005194065 TAFAQQUH FIDINILLAH ELHAQ R.1 [FOI] Tremenza SANB tab Komb 5.00 5,100 13,708

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 8.00 1,152

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731

(Dengan Harga)
26 22 Nov 2019 620 1001545470808 ERTOPO DWIYOGO WIBOWO N [FOI] Metformin HEXP tab salut selaput 500 mg 30.00 5,440 422,400

N [FOI] Januvia 100 mg MSDI tab 100 mg 30.00 339,160

N [STFOI] Hyperchol 300 IKAP kaps 300 mg (Dengan 30.00 77,800

Harga)
27 22 Nov 2019 631 1011005221691 KISADIYANTO N [FOI] Bisoprolol Fumarate HEXP tab salut selaput 5 30.00 24,556 257,556
mg
N [FOI] Lipitor PFIZ tab 20 mg 30.00 189,400

N [FOI] Irbesartan HEXP tab 300 mg tab 15.00 43,600

28 22 Nov 2019 616 1041424961523 SYAUQI GHAISAN ALTAMIS N [STFOI] Burnazin 35 g DAVA krim 1% tube 35 g 1.00 57,520 57,520
VERGINO (Dengan Harga)
29 22 Nov 2019 629 1001005221699 ENDANG SAPRIYANI N [FOI] Azithromycin 500 mg NOVE tab 500 mg 3.00 16,438 33,756

R.1 [FOI] Cetirizine HEXP tab 10 mg 5.00 1,104

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 3.00 432

R.1 [STFOI] Ambroxol 30 mg NOVE tab 30 mg (Dengan 11.00 2,640

Harga)
R.1 [STFOI] Methylprednisolone HEXP tab 16 mg 6.00 6,696
(Dengan Harga)
R.1 [STFOI] Codein KIFA tab 20 mg (Dengan Harga) 3.00 5,846

30 22 Nov 2019 630 1011545483679 RISRIYANI N [FOI] Euthyrox 100 MERC tab 0,1 mg 30.00 64,984 795,425

N [FOI] Loratadine HEXP tab 10 mg 5.00 1,480

N [STFOI] Spiriva Respimat BOEH cairan inhalasi 5 1.00 690,460

mcg/dosis cartridge 30 dosis (Dengan Harga)
R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 5.00 720

R.1 [STFOI] Codein KIFA tab 20 mg (Dengan Harga) 15.00 29,232

R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 8.00 7,949

(Dengan Harga)
31 22 Nov 2019 624 1001537416833 DESTANTIANA NURINA, SH N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 10.00 96,400 268,013

N [FOI] Zistic kapl BERN kapl 500 mg 5.00 136,522

N [STFOI] Sucralfate TEMP susp 500 mg/5 ml btl 100 1.00 15,700
ml (Dengan Harga)
N [STFOI] Domperidone HEXP tab 10 mg (Dengan 10.00 2,548
Harga)
R.1 [FOI] Codikaf KIFA tab 20 mg 4.00 8,237

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 3.00 432

R.1 [STFOI] Ambroxol 30 mg NOVE tab 30 mg (Dengan 15.00 3,600

Harga)
R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 4.00 3,974
(Dengan Harga)
32 22 Nov 2019 617 1011012462178 CINANTYA PINASTHIKA N [FOI] Zistic kapl BERN kapl 500 mg 3.00 82,073 258,756

N [FORRS] Sanmol tab 500 mg 15.00 6,938

N [VISUP] FORMUNO TAB 10.00 90,650

R.1 [FORRS] LAMESON 160MG 5.00 55,965

R.1 [FORRS] RHINOFED TAB 10.00 23,130

33 22 Nov 2019 636 1011488334366 JOHNY HIDAYAT R.1 [STFOI] Domperidone HEXP tab 10 mg (Dengan 45.00 9,666 26,046
Harga)
R.2 [STFOI] Alprazolam 1 mg OTTO tab 1 mg (Dengan 23.00 15,180
Harga)
34 22 Nov 2019 627 1011568260352 MELINDA SARI N [FOI] Allopurinol HEXP tab 100 mg 30.00 5,260 103,620

N [STFOI] Recolfar PRAT tab 0,5 mg (Dengan Harga) 15.00 93,460

N [STFOI] Methylprednisolone HEXP tab 4 mg 15.00 4,900

(Dengan Harga)
35 23 Nov 2019 647 1061012023097 AQMAR HEERAD DANISWARA N [FORRS] ryvel drop 1.00 72,798 80,403

R.1 [FOI] Tremenza SANB tab Komb 3.00 3,060

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 3.00 432

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 4.00 2,388

(Dengan Harga)
36 23 Nov 2019 660 1041464294133 ADELIA MAHESWARI KUSUMANTO N [FOI] Depakene ABBT sir 250 mg/5ml btl 120 ml 2.00 214,732 223,428

N [ALKES] botol tetes 10 ml 1.00 1,573

N [FORRS] chloralhydrat serbuk 1.00 7,123

37 23 Nov 2019 646 1051012023096 NADYA VALINA AZZAHRA N [FORRS] tempra syr 1.00 56,148 108,231

N [FORRS] becombion lys 1.00 39,683

R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 6.00 864

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731

(Dengan Harga)
38 23 Nov 2019 676 1041424961681 CARISSA NUHA FAZILA N [STFOI] Omeprazole HEXP kaps 20 mg (Dengan 20.00 7,528 7,528
Harga)
39 23 Nov 2019 674 1001424946724 NOVIYANI DYAH SISWATI N [FOI] Obimin AF DAVA tab Komb 30.00 40,000 107,972

N [FOI] Cavit D3 MERC tab komb 30.00 67,972

40 23 Nov 2019 645 1011504183355 ALIYA GISTA MAKRIFAT N [ALKES] handschoen steril gammex 7 1.00 26,455 412,500

N [FORRS] Asam Mefenamat BERN tab 500 mg 15.00 5,800

N [FORRS] nova T 1.00 364,173

N [STFOI] Clindamycin 300 mg NOVE kaps 300 mg 10.00 16,072

(Dengan Harga)
41 23 Nov 2019 678 1051426739744 HANIFAH AZZAHRA DIAH N [STFOI] Cefadroxil NLAB kaps 500 mg (Dengan 10.00 7,660 13,025
PITALOKA Harga)
N [STFOI] Deksamethason BERN tab 0,5 mg (Dengan 12.00 1,725
Harga)
N [STFOI] Kalium Diklofenak HEXP tab salut selaput 10.00 3,640
50 mg (Dengan Harga)

SIMO;port;printed @12/4/2019 9:07:11 AM;fauzi_jih Page 2 of 8

 42 23 Nov 2019 666 1041464175884 FATIH AL AYYUBI WIRARAJA N [FORRS] vaksin hexaxim 1.00 831,390 831,390

43 23 Nov 2019 703 1051551356703 FALAH ALKAUTSAR KHAYR N [FORRS] vaksin hexaxim 1.00 831,390 831,390
RIZWAN
44 23 Nov 2019 650 1001424961686 UMI DWI ASYIATUN N [FOI] Glucophage XR 500 MERC tab lepas lambat 30.00 72,580 414,840
500 mg
N [FOI] Crestor 20 mg ASCA tab 20 mg 30.00 288,400

N [STFOI] Hyperchol 100 IKAP kaps 100 mg (Dengan 30.00 53,860

Harga)
45 23 Nov 2019 673 1011551379131 YUSTI ANGGINI N [STFOI] Otopain INTR tts telinga Komb btl 8 ml 1.00 40,000 45,960
(Dengan Harga)
N [STFOI] Paracetamol BERN tab 500 mg (Dengan 10.00 1,960
Harga)
N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 10.00 4,000
Harga)
46 23 Nov 2019 664 1001551377475 DIDIK ARDIASTANTO N [FOI] Glucophage XR 500 MERC tab lepas lambat 30.00 72,580 843,489
500 mg
N [FOI] Exforge 5/80 mg NOVA tab salut selaput Komb 27.00 415,509

N [FOI] Januvia 100 mg MSDI tab 100 mg 30.00 339,160

N [STFOI] Glimepiride HEXP tab 2 mg (Dengan Harga) 30.00 16,240

47 23 Nov 2019 648 1001424961686 UMI DWI ASYIATUN N [STFOI] Eperisone HCl 50 mg NOVE tab 50 mg 15.00 23,962 23,962
(Dengan Harga)
48 23 Nov 2019 649 1001424962226 IRA KUSUMA ANGREYLIYA N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 14.00 13,823 13,823
Harga)
49 23 Nov 2019 652 1001545476671 WISNU HARDJADI N [FOI] Glucophage XR 500 MERC tab lepas lambat 30.00 72,580 76,100
500 mg
N [STFOI] Paracetamol BERN tab 500 mg (Dengan 20.00 3,520
Harga)
50 23 Nov 2019 655 1001545476671 WISNU HARDJADI N [FOI] Bisoprolol Fumarate HEXP tab salut selaput 5 15.00 12,478 532,578
mg
N [FOI] Crestor 10 mg ASCA tab 10 mg 30.00 252,400

N [FOI] Canderin 16 mg DEXA tab 16 mg 30.00 267,700

51 23 Nov 2019 656 1001545476625 BAKRIE ABBAS N [FOI] Avodart GSKI kaps lunak 0,5 mg 30.00 324,400 1,020,000

N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 30.00 288,400

N [STFOI] Harnal Ocas ASTE tab lepas lambat 0,4 mg 30.00 407,200
(Dengan Harga)
52 23 Nov 2019 659 1011009713477 DYAH AYU AGUSTININGSIH N [FOI] Braxidin SANB tab Komb 10.00 13,600 150,096

N [FOI] Lansoprazole 30 mg NOVE kaps 30 mg 15.00 10,498

N [FORRS] INPEPSA 100ML 1.00 72,798

N [STFOI] Sangobion Capsul MERC kaps Komb 40.00 53,200

(Dengan Harga)
53 23 Nov 2019 665 1041009569774 CALYA NAJWA PUTRI INDRIYANI N [FOI] Cefadroxil HEXP sir kering 125 mg/5 ml btl 60 2.00 16,480 18,405
ml
R.1 [STFOI] Deksamethason BERN tab 0,5 mg (Dengan 12.00 1,325
Harga)
54 24 Nov 2019 689 1011014059689 DEWINTHA RATNA P. N [FOI] Obimin AF DAVA tab Komb 10.00 13,600 13,600

55 24 Nov 2019 679 1011551364437 ARIANA RATRININGTIAS N [STFOI] Anelat IFAR kapl 1 mg (Dengan Harga) 30.00 5,476 5,476

56 24 Nov 2019 690 1001014351604 DIEN DESTIANI CAESARI N [FOI] Maltofer Fol Chew COMB tab kunyah 100mg 20.00 69,352 277,076

N [STFOI] Duphaston ABBT tab 10 mg (Dengan 15.00 207,724

Harga)
57 24 Nov 2019 694 1051564131742 NAYAKA ALRESCHA PUJIANTO N [FOI] Interzinc syr INTR sir 20 mg/5 ml btl 60 ml 1.00 22,600 88,090

N [FORRS] Thrombophob LEOP gel 200 Iu/G tube 20 1.00 65,490

mg
58 24 Nov 2019 686 1051551368921 SHAFIYYA GAZZA ADZ-DZIKRA R.1 [FOI] Tremenza SANB tab Komb 3.00 3,060 12,669

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 5.00 720

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 10.00 7,164

(Dengan Harga)
59 24 Nov 2019 683 1041551377479 RIDWAN GIGGSY ARDITHA N [FOI] Singulair TMIN tab 10 mg 14.00 112,322 119,209

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 6.00 864

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 6.00 4,298

(Dengan Harga)
60 24 Nov 2019 685 1051551377471 IBRAHIM RYAN ARDITHA N [STFOI] Elkana SANB susp Komb btl 60 ml (Dengan 1.00 26,800 26,800
Harga)
61 24 Nov 2019 695 1041004084779 KHAIRA ALTHAFUNNISA N [FORRS] PROPYRETIC 240 COM B 240 MG 1.00 10,545 10,545

62 25 Nov 2019 714 1041496710118 DARREL ATHAYA ZARKASYI N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 10.00 9,988 17,552
Harga)
N [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 10.00 7,564
(Dengan Harga)
63 25 Nov 2019 750 1051005194065 TAFAQQUH FIDINILLAH ELHAQ R.1 [FOI] Tremenza SANB tab Komb 5.00 5,100 15,717

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 12.00 1,728

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 10.00 7,164

(Dengan Harga)
64 25 Nov 2019 738 1041542632989 NELVIRA YOLANDA PUTRI N [STFOI] Dermovel FERR krim 0,1% tube 10 g 1.00 41,800 41,800
(Dengan Harga)
65 25 Nov 2019 742 1041464293323 MUHAMMAD ZAYN ALI IBROHIM N [STFOI] Cefixime Trihydrate HEXP sir kering 100 2.00 28,720 28,720
mg/5 ml btl 30 ml (Dengan Harga)
66 25 Nov 2019 702 1051424943849 RONIA RUMAISHA ARIBOWO N [FOI] Tremenza SANB tab Komb 10.00 10,600 32,092

N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 10.00 9,988

Harga)
N [STFOI] Paracetamol BERN tab 500 mg (Dengan 16.00 2,896
Harga)
R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 8.00 1,152

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731

(Dengan Harga)
67 25 Nov 2019 719 1001503298507 YOGA IMANDA PURNAMA N [STFOI] Tarivid FERR tts mata 3 mg/ml btl 5 ml 1.00 48,018 49,522
(Dengan Harga)
N [STFOI] Deksamethason BERN tab 0,5 mg (Dengan 10.00 1,504
Harga)
68 25 Nov 2019 712 1041540955907 DHIA SALMA ALIFA N [FORRS] tempra forte syr 1.00 48,748 120,918

N [FORRS] Omeprazol kaps 20 mg 10.00 6,475

N [FORRS] curvit syr 1.00 61,513

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 5.00 3,582

(Dengan Harga)

SIMO;port;printed @12/4/2019 9:07:11 AM;fauzi_jih Page 3 of 8

 69 25 Nov 2019 741 1051003942931 ARYA GHAISAN AZKA NAFISA N [STFOI] Paracetamol BERN tab 500 mg (Dengan 20.00 3,520 3,520
Harga)
70 25 Nov 2019 747 1011489637533 AMALNI N [FOI] Urdahex DANK kaps 250 mg 10.00 57,604 64,736

N [FOI] Lansoprazole 30 mg NOVE kaps 30 mg 10.00 7,132

71 25 Nov 2019 703 1011515066921 MARHAMAH N [FOI] Clopidogrel Bisulfate HEXP kapl salut selaput 30.00 108,328 296,328
75 mg
N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 15.00 144,400

N [FOI] Atorvastatin 20 mg NOVE tab 20 mg 15.00 43,600

72 25 Nov 2019 705 1001545473328 SITI NURLELA N [FOI] Crestor 20 mg ASCA tab 20 mg 30.00 288,400 288,400

73 25 Nov 2019 740 1051440183257 AKBARSYAH NUR IMAN M. N [FOI] Braxidin SANB tab Komb 30.00 40,000 83,344

N [STFOI] Merlopam 2 MERS tab salut selaput 2 mg 14.00 36,688

(Dengan Harga)
R.1 [STFOI] Alprazolam 1 mg OTTO tab 1 mg (Dengan 7.00 4,620
Harga)
R.1 [STFOI] Amitriptyline INFA tab 25 mg (Dengan 7.00 1,436
Harga)
74 25 Nov 2019 743 1001426750133 AZMIL ULULI FITHROTIEN N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 28.00 269,200 282,536

N [STFOI] Primperan 10 SOHO tab 10 mg (Dengan 14.00 13,336

Harga)
75 25 Nov 2019 722 1001476765719 JUARIANTO , S.AP N [FOI] Leptica 75 mg DEXA kaps 75 mg 10.00 95,440 99,200

N [STFOI] Meloxicam 7,5 HEXP tab 7,5 mg (Dengan 10.00 3,760

Harga)
76 25 Nov 2019 735 1011545483679 RISRIYANI N [FOI] Rhinos SR DEXA kapl sustained release Komb 15.00 91,624 1,386,264

N [STFOI] Mestinon TMIN tab 60 mg (Dengan Harga) 120.00 1,289,200

N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 14.00 5,440

Harga)
77 25 Nov 2019 721 1001012669324 MOCHAMAD CHAERUL ANWAR N [STFOI] Natrium Diklofenak BERN tab 50 mg 14.00 3,088 37,288
(Dengan Harga)
R.1 [STFOI] Paracetamol BERN tab 500 mg (Dengan 14.00 2,184
Harga)
R.1 [STFOI] Eperisone HCl 50 mg NOVE tab 50 mg 20.00 31,416
(Dengan Harga)
78 25 Nov 2019 734 1051544597624 ANANDA YUSUF HARIYANTO N [FORRS] Omeprazol kaps 20 mg 10.00 6,475 62,068

N [FORRS] Alco Plus Dmp INTR sir komb 1.00 55,593

79 26 Nov 2019 772 1001464169196 DIAH SONANTI N [ALKES] handschoen steril 7 gammex 1.00 26,455 68,255

N [STFOI] Dermovel FERR krim 0,1% tube 10 g 1.00 41,800

(Dengan Harga)
80 26 Nov 2019 762 1051493379851 ALMER RASYA ATMOKO N [STFOI] Cefixime Trihydrate HEXP sir kering 100 1.00 14,560 20,941
mg/5 ml btl 30 ml (Dengan Harga)
R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 4.00 576

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

81 26 Nov 2019 795 1081009718627 HANI AINANI PUTRI N [FORRS] Ataroc NOVE sir 5 mcg/ml 1.00 61,513 105,173

N [FORRS] Rhinos Junior DEXA sir Komb btl 60 ml 1.00 43,660

82 26 Nov 2019 796 1061009718625 HANA AINANI PUTRI N [FORRS] Ibuprofen YARI tab salut selaput 200 mg 10.00 2,620 41,184

N [FORRS] Acyclovir krim 50 mg 4.00 23,044

N [STFOI] Acyclovir HEXP tab 400 mg (Dengan Harga) 30.00 15,520

83 26 Nov 2019 793 1041008106609 KHANSA TSABITA N [FOI] Claneksi DS SANB sir kering Komb btl 60 ml 1.00 40,600 45,800

N [STFOI] Paracetamol BERN sir 120 mg/5 ml btl 60 ml 1.00 5,200

(Dengan Harga)
84 26 Nov 2019 761 1011009664001 FATIMATUS ZUHRA N [FORRS] cal 95 tab 30.00 208,125 457,875

N [FORRS] emineton tab 30.00 61,050

N [FORRS] prolacta for mother 30.00 188,700

85 26 Nov 2019 758 1041012179831 GHANIA KINARIAN PRASETYO N [ALKES] spuit 1 cc terumo 1.00 8,510 52,170

N [FORRS] Vaksin Bcg Kering BIOF serb inj 0,375 1.00 43,660
mg/ml amp
86 26 Nov 2019 752 1011435343154 RINA DAROJATI N [FOI] Bisoprolol Fumarate HEXP tab salut selaput 5 30.00 24,556 94,256
mg
N [STFOI] Simarc 2 PRAT tab 2 mg (Dengan Harga) 50.00 69,700

87 26 Nov 2019 753 1011487583327 FAZILATHUNISYA N [STFOI] Furosemid KIFA tab 40 mg (Dengan Harga) 8.00 1,456 12,522

N [STFOI] Spironolactone 100 mg OTTO tab 100 mg 8.00 11,066

(Dengan Harga)
88 26 Nov 2019 768 1011545479337 ENDANG SRI WAHYUNI N [FOI] Metformin HEXP tab salut selaput 500 mg 90.00 15,520 890,806

N [FOI] Crestor 10 mg ASCA tab 10 mg 30.00 252,400

N [FOI] Diamicron MR 60 SERV tab lepas lambat 60 mg 45.00 306,310

N [STFOI] Januvia 100 mg MSDI tab 100 mg (Dengan 28.00 316,576

Harga)
89 26 Nov 2019 785 1001521596554 KURNIA ISNAINI R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 8.00 7,949 14,251
(Dengan Harga)
R.1 [STFOI] Valisanbe SANB tab 5 mg (Dengan Harga) 12.00 5,702

90 26 Nov 2019 792 1001565075161 ARMY LUBIS, SE N [FOI] Clopidogrel Bisulfate HEXP kapl salut selaput 30.00 108,328 195,128
75 mg
N [FOI] Atorvastatin 20 mg NOVE tab 20 mg 30.00 86,800

91 26 Nov 2019 778 1001435352412 JOHN HUKOM N [STFOI] Paracetamol BERN tab 500 mg (Dengan 14.00 2,584 6,529
Harga)
N [STFOI] Metronidazole BERN tab 500 mg (Dengan 14.00 3,945
Harga)
92 26 Nov 2019 781 1001540954158 IRFAN TUGIMAN N [FOI] Crestor 20 mg ASCA tab 20 mg 30.00 288,400 565,900

N [HERBA] livercare cap (liverprime) cap 30.00 277,500

93 26 Nov 2019 774 1001004095169 LUS HARYANTO R.1 [STFOI] Paracetamol BERN tab 500 mg (Dengan 72.00 11,232 14,683
Harga)
R.1 [STFOI] Valisanbe SANB tab 5 mg (Dengan Harga) 6.00 2,851

94 26 Nov 2019 764 1011568260352 MELINDA SARI N [FOI] Leptica 75 mg DEXA kaps 75 mg 14.00 133,456 133,456

95 26 Nov 2019 769 1041542647389 JEVENTRI M.H N [STFOI] Otopain INTR tts telinga Komb btl 8 ml 1.00 40,000 40,000
(Dengan Harga)
96 26 Nov 2019 756 1001540953473 EKI KARMANTO N [FOI] Metformin HEXP tab salut selaput 500 mg 30.00 5,440 5,440

97 26 Nov 2019 773 1001463681497 MOHAMAD ISMET, DR, IR, MSC N [FOI] Norvask PFIZ tab 5 mg 30.00 77,800 1,301,616

N [FOI] Glucophage XR 750 MERC tab lepas lambat 30.00 75,676

750 mg

SIMO;port;printed @12/4/2019 9:07:11 AM;fauzi_jih Page 4 of 8

 N [FORRS] lipitor tab 10 mg 30.00 740,940

N [STFOI] Harnal Ocas ASTE tab lepas lambat 0,4 mg 30.00 407,200
(Dengan Harga)
98 26 Nov 2019 782 1001532492999 ADI SETIOKO N [STFOI] Betahistine 6 mg NOVE tab 6 mg (Dengan 10.00 6,496 18,150
Harga)
N [STFOI] Domperidone HEXP tab 10 mg (Dengan 10.00 2,548
Harga)
R.1 [FOI] Cetirizine HEXP tab 10 mg 5.00 1,104

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 2.00 288

R.1 [STFOI] Ambroxol 30 mg NOVE tab 30 mg (Dengan 8.00 1,920

Harga)
R.1 [STFOI] Codein KIFA tab 15 mg (Dengan Harga) 2.00 2,962

R.1 [STFOI] Methylprednisolone HEXP tab 16 mg 2.00 2,232

(Dengan Harga)
99 26 Nov 2019 776 1011487583327 FAZILATHUNISYA N [FOI] Symbicort Turb 160 ASCA serb inh Komb 2.00 483,400 515,144
turbuhaler 60 dosis
N [FOI] Loratadine HEXP tab 10 mg 5.00 1,480

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 3.00 432

R.1 [STFOI] Codein KIFA tab 20 mg (Dengan Harga) 15.00 29,232

100 26 Nov 2019 777 1001435352412 JOHN HUKOM N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 30.00 288,400 292,100

N [STFOI] Alprazolam 1 mg OTTO tab 1 mg (Dengan 5.00 3,700

Harga)
101 26 Nov 2019 780 1041503290198 TIFA AYU PRADITYA N [FORRS] Buscopan plus tablet 6.00 32,190 38,890

N [STFOI] Levofloxacin NOVE tab 500 mg (Dengan 7.00 6,700

Harga)
102 27 Nov 2019 617 1011006326338 VIVI YUNANINGSIH N [ALKES] handschoen steril 1.00 26,455 102,063

N [STFOI] Kalnex KALB tab 500 mg (Dengan Harga) 30.00 68,800

N [STFOI] Asam mefenamat BERN tab 500 mg 30.00 6,808

(Dengan Harga)
103 27 Nov 2019 800 1041424971041 DAFFA KHAIRI HILMI N [STFOI] Cefixime Trihydrate HEXP sir kering 100 2.00 28,720 43,861
mg/5 ml btl 30 ml (Dengan Harga)
R.1 [FOI] Tremenza SANB tab Komb 5.00 5,100

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 8.00 1,152

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 10.00 7,164

(Dengan Harga)
104 27 Nov 2019 835 1001464176576 ANDHITA PUTRI AMALIA N [FOI] Cyclo Progynova BAYR tab Komb strip 21 1.00 150,657 150,657

105 27 Nov 2019 820 1001004087396 ARNOLD DWI NOVRIANTO N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 10.00 9,988 9,988
Harga)
106 27 Nov 2019 830 1051544597624 ANANDA YUSUF HARIYANTO N [FORRS] Norages sir 250 mg/5 ml btl 60 ml 1.00 42,365 46,329

N [STFOI] Omeprazole HEXP kaps 20 mg (Dengan 10.00 3,964

Harga)
107 27 Nov 2019 807 1001463655792 MESTIKA N [FORRS] Antasida Doen RAMA susp komb btl 60 ml 1.00 6,949 22,649

N [STFOI] Sucralfate TEMP susp 500 mg/5 ml btl 100 1.00 15,700
ml (Dengan Harga)
108 27 Nov 2019 808 1011014059173 DIKLUSARI ISNAROSI N [ALKES] HANDSCHOEN STERIL 1.00 26,455 80,409

N [FORRS] Asam Traneksamat BERN tab 500 mg 15.00 50,350

N [STFOI] Asam mefenamat BERN tab 500 mg 15.00 3,604

(Dengan Harga)
109 27 Nov 2019 811 1081009718627 HANI AINANI PUTRI N [FORRS] CENDO VASACON A ED 15 ML 1.00 29,600 122,193

N [FORRS] OPTIMAX SYR 1.00 92,593

110 27 Nov 2019 814 1001545475804 PALGUNADI N [FOI] Metformin HEXP tab salut selaput 500 mg 60.00 10,480 160,040

N [FOI] Amlodipin Besylat LAND tab 10 mg 30.00 10,120

N [FOI] Atorvastatin 20 mg NOVE tab 20 mg 30.00 86,800

N [FOI] Thrombo Aspilet EC DAVA tab 80 mg 30.00 20,560

N [STFOI] Glimepiride HEXP tab 2 mg (Dengan Harga) 60.00 32,080

111 27 Nov 2019 803 1011533370028 CHAIRIL ANWAR N [FOI] Metformin HEXP tab salut selaput 500 mg 60.00 10,480 707,200

N [FOI] Lipitor PFIZ tab 40 mg 30.00 193,000

N [STFOI] Pletaal tablet 50 mg OTSU tab 50 mg 60.00 396,400

(Dengan Harga)
N [STFOI] Candesartan 8 mg NOVE tab 8 mg 30.00 107,320
(Dengan Harga)
112 27 Nov 2019 801 1011463649886 RETNO HANDAYANI N [FOI] Irbesartan HEXP tab 300 mg tab 30.00 86,800 206,070

N [FOI] Lansoprazole 30 mg NOVE kaps 30 mg 15.00 10,498

N [FOI] Amlodipin Besylat LAND tab 10 mg 30.00 10,120

N [STFOI] Anelat IFAR kapl 1 mg (Dengan Harga) 90.00 15,628

N [STFOI] Calos PRAT tab 500 mg (Dengan Harga) 90.00 74,704

N [STFOI] Furosemid KIFA tab 40 mg (Dengan Harga) 60.00 8,320

113 27 Nov 2019 816 1011551368926 FRANSISKA DHITA WISESA, ST, N [FOI] Nasacort AQ AVEN nasal spray 55 mcg/dosis 1.00 163,873 463,583
M.ENG. btl 120 dosis
N [FOI] Singulair TMIN tab 10 mg 35.00 280,204

R.1 [FOI] Tremenza SANB tab Komb 8.00 8,160

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 15.00 10,746

(Dengan Harga)
114 27 Nov 2019 823 1001010813131 AGUS PRAYITNO N [FORRS] orinox 5.00 49,950 214,313

R.1 [FORRS] feldene gel 15 gr 1.00 98,050

R.1 [FORRS] voltaren gel 10 gr 1.00 57,535

R.1 [FORRS] pot 30g 1.00 4,810

R.1 [FORRS] minyak gandapura 1.00 3,968

115 27 Nov 2019 828 1041440185754 ANNISA ISLAMY MAHARANI N [FOI] Rhinos SR DEXA kapl sustained release Komb 10.00 61,216 67,016

N [STFOI] Ciprofloxacin BERN tab 500 mg (Dengan 10.00 5,800

Harga)
116 27 Nov 2019 819 1021004087398 ANDINA ERSA N [FOI] Rhinos SR DEXA kapl sustained release Komb 15.00 91,624 91,624

117 27 Nov 2019 827 1001545476671 WISNU HARDJADI N [FOI] Clopidogrel Bisulfate HEXP kapl salut selaput 30.00 108,328 806,844
75 mg
N [STFOI] Anelat IFAR kapl 1 mg (Dengan Harga) 60.00 10,552

N [STFOI] Aricept Evess 10 mg EISA tab dispersible 10 30.00 687,964

mg (Dengan Harga)
118 27 Nov 2019 826 1011463696124 AFRIATY N [FOI] Singulair TMIN tab 10 mg 30.00 240,232 323,396

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 N [STFOI] Eperisone HCl 50 mg NOVE tab 50 mg 10.00 16,108
(Dengan Harga)
R.1 [FOI] Meptin tablet OTSU tab 50 mcg 10.00 42,000

R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 5.00 4,968

(Dengan Harga)
R.1 [STFOI] Codein KIFA tab 20 mg (Dengan Harga) 10.00 19,488

119 28 Nov 2019 775 1001004095169 LUS HARYANTO N [FOI] Bisoprolol Fumarate HEXP tab salut selaput 5 15.00 12,478 271,726
mg
N [FOI] Clopidogrel Bisulfate HEXP kapl salut selaput 30.00 108,328
75 mg
N [FOI] Atorvastatin 20 mg NOVE tab 20 mg 15.00 43,600

N [STFOI] Candesartan 8 mg NOVE tab 8 mg 30.00 107,320

(Dengan Harga)
120 28 Nov 2019 859 1001545473328 SITI NURLELA N [STFOI] Kalium Diklofenak HEXP tab salut selaput 6.00 2,344 2,344
50 mg (Dengan Harga)
121 28 Nov 2019 857 1041011234177 IRGI ALFAREZEL HERTANTO N [FOI] Cefixime Trihydrate HEXP sir kering 100 mg/5 2.00 28,720 36,840
ml btl 30 ml
R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 6.00 864

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731

(Dengan Harga)
122 28 Nov 2019 858 1051011234178 QUEENARA ALFATHUNNISA N [FOI] Cefixime Trihydrate HEXP sir kering 100 mg/5 1.00 14,560 29,141
HERTANTO ml btl 30 ml
N [FOI] Pamol supp 125 mg INTR supp 125 mg 1.00 8,200

R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 4.00 576

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

123 28 Nov 2019 875 1011464261559 NUR ANNA WAHYU NINGSIH N [FOI] Cavit D3 MERC tab komb 30.00 67,972 326,047

N [FORRS] lactafar tab 30.00 160,950

N [FORRS] Kalmeco KALB kaps 500 mcg 30.00 97,125

124 28 Nov 2019 867 1041540966549 FEBRIAN AQILA BASCOND N [FOI] Combivent UDV BOEH cairan inhalasi Komb vial 3.00 38,402 204,766
2,5 ml
N [FORRS] Claneksi Forte sirup SANB Botol 250/62.5 1.00 97,495
mg per 5 ml
N [FORRS] Tempra Forte Taisho Sir 250 mg/5 ml btl 60 1.00 48,748
ml
R.1 [FOI] Tremenza SANB tab Komb 10.00 10,200

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Salbutamol 2 mg KIFA tab 2 mg (Dengan 10.00 1,032

Harga)
R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 10.00 7,164
(Dengan Harga)
125 28 Nov 2019 871 1011011852013 LAKSMI DAMAYANTI N [FOI] Obimin AF DAVA tab Komb 30.00 40,000 107,972

N [FOI] Cavit D3 MERC tab komb 30.00 67,972

126 28 Nov 2019 876 1041523589992 SHANNON MARZUKIE R.1 [FOI] Klorfeniramin Maleat (CTM) APTK tab 4 mg 5.00 624 5,556

R.1 [FOI] Kapsul Kosong Apt Kapsul 10.00 750

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 5.00 3,582

(Dengan Harga)
127 28 Nov 2019 868 1041426773583 KUMARA EMIR ABQARY N [FOI] Cefixime Trihydrate HEXP sir kering 100 mg/5 1.00 14,560 24,219
ml btl 30 ml
R.1 [FOI] Tremenza SANB tab Komb 3.00 3,060

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 4.00 576

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 6.00 4,298

(Dengan Harga)
128 28 Nov 2019 879 1001011234241 INTEN LAYUNGSARI N [STFOI] Cefixime HEXP kaps 100 mg (Dengan 10.00 9,988 9,988
Harga)
129 28 Nov 2019 861 1001435352412 JOHN HUKOM N [STFOI] Metronidazole BERN tab 500 mg (Dengan 14.00 3,945 3,945
Harga)
130 28 Nov 2019 848 1001463661541 M. TOJIB N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 10.00 4,000 4,000
Harga)
131 28 Nov 2019 849 1011463661542 RETNO PERTIWI N [FOI] Loratadine HEXP tab 10 mg 5.00 1,480 108,416

N [FOI] Singulair TMIN tab 10 mg 10.00 80,344

R.1 [FOI] Codikaf KIFA tab 20 mg 10.00 20,592

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 3.00 432

R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 5.00 4,968

(Dengan Harga)
132 28 Nov 2019 870 1001440186176 SRI WIDYOWATI.SE N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 6.00 2,560 18,668
Harga)
N [STFOI] Eperisone HCl 50 mg NOVE tab 50 mg 10.00 16,108
(Dengan Harga)
133 29 Nov 2019 843 1041424963525 NAREEZA ZAFHIRA N [FOI] Cefixime Trihydrate HEXP sir kering 100 mg/5 2.00 28,720 35,196
ml btl 30 ml
N [STFOI] Omeprazole 20 mg NOVE kaps 20 mg 10.00 3,928
(Dengan Harga)
N [STFOI] Domperidone HEXP tab 10 mg (Dengan 10.00 2,548
Harga)
134 29 Nov 2019 891 1011010276023 INDRI CAHAYANI N [FORRS] cendo eyefresh MD 1.00 40,515 76,128

N [FORRS] cendo polynel ED 1.00 35,613

135 29 Nov 2019 901 1001540969651 MOCHAMAD SOFIAN N [FORRS] Prorenal NOVE kapl Komb 25.00 198,875 198,875

136 29 Nov 2019 895 1001007730146 DESKONA WIRASNO N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 14.00 134,800 150,500

N [STFOI] Sucralfate TEMP susp 500 mg/5 ml btl 100 1.00 15,700
ml (Dengan Harga)
137 29 Nov 2019 896 1011551361333 ANTIK HENDRA WULANDARI, SP. N [STFOI] Meloxicam 7,5 HEXP tab 7,5 mg (Dengan 10.00 3,760 13,524
Harga)
N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 15.00 5,800
Harga)
N [STFOI] Omeprazole HEXP kaps 20 mg (Dengan 10.00 3,964
Harga)
138 29 Nov 2019 886 1001492690242 SUSIATY HANDAYANI N [FOI] Pantoprazole tab 40 mg MBFA tab 40 mg 14.00 134,800 134,800

139 29 Nov 2019 890 1011010276023 INDRI CAHAYANI N [STFOI] Thyrozol 10 MERC tab salut selaput 10 mg 60.00 116,104 124,208
(Dengan Harga)
N [STFOI] Propranolol HCl APTK tab 10 mg (Dengan 60.00 8,104
Harga)
140 29 Nov 2019 906 1001550574271 RIESKA DESTIANA INDRAJAYA N [FOI] Otopain INTR tts telinga Komb btl 8 ml 1.00 40,000 40,000

141 29 Nov 2019 907 1001011046916 DIAN RAHMASARI N [STFOI] Betahistine 6 mg NOVE tab 6 mg (Dengan 15.00 9,544 9,544
Harga)

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 142 29 Nov 2019 908 1011551379131 YUSTI ANGGINI N [STFOI] Acyclovir 200 mg NOVE tab 200 mg 70.00 38,452 68,660
(Dengan Harga)
N [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 30.00 30,208
(Dengan Harga)
143 29 Nov 2019 919 1001470299917 RENDY HANDHIKA SANJAYA N [FOI] Cefadroxil BERN kaps 500 mg 8.00 6,208 9,789

R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 3.00 2,981

(Dengan Harga)
144 29 Nov 2019 920 1041435342303 MALWA HAZWANI NUR A. N [FOI] Cefadroxil BERN kaps 500 mg 8.00 6,208 17,413

N [FOI] Cetirizine HEXP tab 10 mg 5.00 1,504

R.1 [FOI] Tremenza SANB tab Komb 6.00 6,120

R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 3.00 2,981

(Dengan Harga)
145 29 Nov 2019 905 1011011046917 LEO WIDODO N [FOI] Symbicort Turb 160 ASCA serb inh Komb 2.00 483,400 492,018
turbuhaler 60 dosis
N [FOI] Loratadine HEXP tab 10 mg 5.00 1,480

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 4.00 576

R.1 [STFOI] Methylprednisolone 16 mg NOVE tab 16 mg 6.00 5,962

(Dengan Harga)
146 29 Nov 2019 894 1051009705541 SHAFIRA KAMILA AULIA N [FORRS] Deslotin DEXA tab 5 mg 15.00 99,900 961,939

N [FORRS] fluimuicil syr 75 ml 1.00 72,705

N [STFOI] PRO TB4 PHAP tab Komb (Dengan Harga) 84.00 492,506

N [STFOI] Piridoksin HCl (Vitamin B6) 10 mg KIFA tab 21.00 3,500

10 mg (Dengan Harga)
N [VISUP] lesichol 300 mg tab 21.00 293,328

147 29 Nov 2019 917 1001010812049 MUKSONI R.1 [FORRS] Cipralex tab salut selaput 5 mg 21.00 507,003 551,446

R.1 [STFOI] Alprazolam 1 mg OTTO tab 1 mg (Dengan 22.00 14,520

Harga)
R.1 [STFOI] Primperan 10 SOHO tab 10 mg (Dengan 28.00 25,872
Harga)
R.2 [STFOI] Valisanbe SANB tab 5 mg (Dengan Harga) 6.00 2,851

148 30 Nov 2019 947 1051011233831 MUHAMMAD ZAIN AR RAFIF R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080 9,247

R.1 [FOI] Salbutamol 4 mg GRAF tab 4 mg 4.00 576

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 4.00 2,866

(Dengan Harga)
149 30 Nov 2019 921 1001491294961 ELLY DITANINGSIH N [FOI] Cavit D3 MERC tab komb 7.00 16,167 16,167

150 30 Nov 2019 924 1011551379164 DIAH KUSUMA WARDANI N [ALKES] HANDSCHOEN STERIL 6,5 GAMMEX 2.00 52,910 74,645

N [ALKES] SPUIT 10 CC TERUMO 1.00 9,713

N [FORRS] NACL 0,9 % 25 ML 1.00 8,418

N [STFOI] Asam mefenamat BERN tab 500 mg 15.00 3,604

(Dengan Harga)
151 30 Nov 2019 930 1001551374887 MARIA MELANIE CYNTHIA ANWAR N [STFOI] Duphaston ABBT tab 10 mg (Dengan 28.00 387,405 387,405
Harga)
152 30 Nov 2019 959 1041464293323 MUHAMMAD ZAYN ALI IBROHIM N [FORRS] Ventolin GLAX sir 2 mg/ml 1.00 65,583 125,153

N [FORRS] Rhinos Neo DEXA drop 7,5 mg/0,8 ml btl 10 1.00 59,570
ml
153 30 Nov 2019 952 1041014304505 ATHARIZ KIAN PRATAMA R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125 4,749

R.1 [STFOI] Acyclovir HEXP tab 400 mg (Dengan Harga) 6.00 3,024

154 30 Nov 2019 954 1011514361038 AYU PUSPITA RINI N [STFOI] Ondansetron 4 mg INFA tab 4 mg (Dengan 30.00 29,128 29,128
Harga)
155 30 Nov 2019 927 1051424971042 HANIF AUFA SYARIF N [STFOI] Cefixime Trihydrate HEXP sir kering 100 1.00 14,560 26,696
mg/5 ml btl 30 ml (Dengan Harga)
R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Salbutamol 4 mg GRAF tab 4 mg (Dengan 5.00 600

Harga)
R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 8.00 5,731
(Dengan Harga)
156 30 Nov 2019 944 1051014687401 SARAH SADIYA AZZAHRA R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080 9,247

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Salbutamol 4 mg GRAF tab 4 mg (Dengan 4.00 576

Harga)
R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 4.00 2,866
(Dengan Harga)
157 30 Nov 2019 945 1041014687409 FAUZIA NAJMA FATIHA R.1 [FOI] Tremenza SANB tab Komb 4.00 4,080 10,967

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [STFOI] Salbutamol 4 mg GRAF tab 4 mg (Dengan 6.00 864

Harga)
R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 6.00 4,298
(Dengan Harga)
158 30 Nov 2019 922 1051455073476 NADANTA CATRAVEDHA ARETAS R.1 [FOI] Tremenza SANB tab Komb 15.00 15,300 122,121

R.1 [FOI] Kapsul Kosong Apt Kapsul 15.00 1,125

R.1 [FORRS] VECTRIN TAB 15.00 94,350

R.1 [STFOI] Triamcinolone 4 mg NOVE tab 4 mg 15.00 10,746

(Dengan Harga)
159 30 Nov 2019 928 1011424971047 MERYANA N [ALKES] HANDSCHOEN STERIL 6,5 GAMMEX 3.00 79,365 79,365

160 30 Nov 2019 943 1041540955907 DHIA SALMA ALIFA N [FOI] Forumen SANB tts telinga 5 mg/ml btl 10 ml 1.00 25,780 40,436

N [STFOI] Amoxicillin NLAB sir kering 125 mg/5 ml btl 2.00 14,656
60 ml (Dengan Harga)
161 30 Nov 2019 955 1061005194527 CHRISTABELA JOPINGKAN N [FOI] Otopain INTR tts telinga Komb btl 8 ml 1.00 40,000 40,000

162 30 Nov 2019 951 1011424959393 RAMADHENA DWI PUTRI N [FOI] Lansoprazole 30 mg NOVE kaps 30 mg 7.00 5,112 32,607

N [STFOI] Eperisone HCl 50 mg NOVE tab 50 mg 14.00 22,391

(Dengan Harga)
N [STFOI] Meloxicam 7,5 HEXP tab 7,5 mg (Dengan 14.00 5,104
Harga)
163 30 Nov 2019 948 1001545482508 SYARIFUDIN SALEH N [STFOI] Alprazolam 1 mg OTTO tab 1 mg (Dengan 30.00 20,200 98,360
Harga)
N [STFOI] Merlopam 2 MERS tab salut selaput 2 mg 30.00 78,160
(Dengan Harga)
164 30 Nov 2019 938 1011442302044 YULIA PURWANTI N [FOI] Crestor 20 mg ASCA tab 20 mg 30.00 288,400 864,708

N [FOI] Gabapentin 300 mg NOVE kaps 300 mg 30.00 96,448

N [FOI] Allopurinol HEXP tab 100 mg 30.00 5,260

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 N [FOI] Galvus NOVA tab 50 mg 30.00 216,400

N [STFOI] Diamicron MR 60 SERV tab lepas lambat 60 30.00 204,340

mg (Dengan Harga)
N [STFOI] Hyperchol 100 IKAP kaps 100 mg (Dengan 30.00 53,860
Harga)
165 30 Nov 2019 935 1001476765719 JUARIANTO , S.AP N [FOI] Leptica 75 mg DEXA kaps 75 mg 12.00 114,448 128,644

N [STFOI] Meloxicam 7,5 HEXP tab 7,5 mg (Dengan 12.00 4,432

Harga)
N [STFOI] Methylprednisolon BERN tab 4 mg (Dengan 15.00 5,800
Harga)
N [STFOI] Omeprazole HEXP kaps 20 mg (Dengan 10.00 3,964
Harga)
166 30 Nov 2019 931 1011010548982 ESTI APRILIA MIKATSI N [FOI] Crestor 20 mg ASCA tab 20 mg 30.00 288,400 499,476

N [FOI] Diamicron MR 60 SERV tab lepas lambat 60 mg 30.00 204,340

N [FOI] Amlodipine besylate HEXP tab 5 mg 30.00 6,736

167 30 Nov 2019 942 1001539575011 DEASY LISA BETTY R.1 [STFOI] Provelyn 75 KALB kaps 75 mg (Dengan 10.00 83,400 123,240
Harga)
R.2 [FOI] Inerson INTR salep 0,25% tube 15 gr 1.00 38,640

168 30 Nov 2019 946 1041464294133 ADELIA MAHESWARI KUSUMANTO N [FORRS] Depakene ABBT sir 250 mg/5 ml btl 120 ml 2.00 414,585 414,585

31,313,480

........................................., 04-Dec-2019
Menyetujui

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