No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl.

Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

GIYONO / SUDI
1 1 0177A01003200000027 0177r0080320v000012 647200596 6/3/2020 2/3/2020 9/3/2020 30.765 0
WIYONO

2 2 0177A01003200000028 0177r0080320v000031 94795795 SUMARJILAH 6/3/2020 2/3/2020 9/3/2020 450.224 0

3 3 0177A01003200000029 0177r0080320v000083 648031735 PARIYAH 6/3/2020 2/3/2020 9/3/2020 141.311 0

4 4 0177A01003200000030 0177r0080320v000014 646746715 WAKIJO 6/3/2020 2/3/2020 9/3/2020 703.72 0
5 5 0177A01003200000031 0177r0080320v000084 648608488 DARIYEM 6/3/2020 2/3/2020 9/3/2020 23.464 0
6 6 0177A01003200000032 0177r0080320v000086 1034142737 RAJILAH 6/3/2020 2/3/2020 9/3/2020 123.072 0
7 7 0177A01003200000033 0177r0080320v000019 1866509921 SURONO 6/3/2020 2/3/2020 9/3/2020 75.734 0
8 8 0177A01003200000034 0177r0080320v000085 648279617 JUMINAH 6/3/2020 2/3/2020 9/3/2020 34.474 0
9 9 0177A01003200000035 0177r0080320v000024 2761217831 DJINEM 6/3/2020 2/3/2020 9/3/2020 39.272 0
10 10 0177A01003200000036 0177r0080320v000015 1093324781 SUWARDI 6/3/2020 2/3/2020 9/3/2020 55.289 0

11 11 0177A01003200000037 0177r0080320v000082 97279345 Dra. HARJANTI 6/3/2020 2/3/2020 9/3/2020 597.154 0

12 12 0177A01003200000038 0177r0080320v000020 1034310936 SUKARNI 6/3/2020 2/3/2020 9/3/2020 18.253 0

13 13 0177A01003200000039 0177r0080320v000080 647954921 RUBINEM 6/3/2020 2/3/2020 9/3/2020 100.95 0

14 14 0177A01003200000040 0177r0080320v000016 1262243507 SRI AYEM 6/3/2020 2/3/2020 9/3/2020 1.031.886 0

15 15 0177A01003200000041 0177r0080320v000061 649830565 PONIRAH 6/3/2020 2/3/2020 9/3/2020 21.873 0

SETYO BUDI
16 16 0177A01003200000042 0177r0080320v000069 1868640759 ASMORO 6/3/2020 2/3/2020 9/3/2020 160.663 0
TASIYO
17 17 0177A01003200000043 0177r0080320v000065 94813694 SUYATI 6/3/2020 2/3/2020 9/3/2020 80.961 0
MADIYO
18 18 0177A01003200000044 0177r0080320v000070 647386784 6/3/2020 2/3/2020 9/3/2020 123.779 0
DIHARJO
AMIN
19 19 0177A01003200000045 0177r0080320v000058 647348949 6/3/2020 2/3/2020 9/3/2020 327.225 0
MURSIDAH
20 20 0177A01003200000046 0177r0080320v000027 650488498 MUH JADIR 6/3/2020 2/3/2020 9/3/2020 85.082 0
21 21 0177A01003200000047 0177r0080320v000074 94485036 DARWATI 6/3/2020 2/3/2020 9/3/2020 675.508 0
22 22 0177A01003200000048 0177r0080320v000033 1875473943 SUMARTINI 6/3/2020 2/3/2020 9/3/2020 479.517 0
23 23 0177A01003200000049 0177r0080320v000026 648986343 MARYADI 6/3/2020 2/3/2020 9/3/2020 13.425 0
24 24 0177A01003200000050 0177r0080320v000025 647357343 HADIYAH 6/3/2020 2/3/2020 9/3/2020 250.005 0
25 25 0177A01003200000051 0177r0080320v000081 95053375 SUMIYATI 6/3/2020 2/3/2020 9/3/2020 791.864 0
26 26 0177A01003200000052 0177r0080320v000062 649830238 SAMIJAN 6/3/2020 2/3/2020 9/3/2020 5.123 0
H.M.
27 27 0177A01003200000053 0177r0080320v000059 94997709 6/3/2020 2/3/2020 9/3/2020 595.962 0
YAINUDIN

28 28 0177A01003200000054 0177r0080320v000079 648106931 WINURJIKAH 6/3/2020 2/3/2020 9/3/2020 68.537 0

29 29 0177A01003200000055 0177r0080320v000021 94798405 SUGIRAH 6/3/2020 2/3/2020 9/3/2020 2.208 0

HAIKAL OKTA
30 30 0177A01003200000056 0177r0080320v000028 648400004 6/3/2020 2/3/2020 9/3/2020 540.989 0
FITRIAN
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif
WIDI
1 605 0177A01011190000670 0177r0081119v001591 648714824 29/11/2019 26/11/2019 3/12/2019 211.037 0
UTOMO

2 606 0177A01011190000671 0177r0081119v001647 1034095814 RASIYEM 29/11/2019 26/11/2019 3/12/2019 27.88 0

3 608 0177A01011190000673 0177r0081119v001583 650437773 JUMILAH 29/11/2019 26/11/2019 3/12/2019 60.735 0

SITI
4 609 0177A01011190000674 0177r0081119v001539 94553627 29/11/2019 26/11/2019 3/12/2019 815.239 0
HUSAINAH

5 610 0177A01011190000675 0177r0081119v001560 94872824 MURJATI 29/11/2019 26/11/2019 3/12/2019 536.748 0

6 611 0177A01011190000676 0177r0081119v001557 94983502 SUGIJONO 29/11/2019 26/11/2019 3/12/2019 145.797 0

SUHARDI
7 612 0177A01011190000677 0177r0081119v001561 648816208 HARDI 29/11/2019 26/11/2019 3/12/2019 95.768 0
WARSITO
MARDI
8 613 0177A01011190000678 0177r0081119v001559 647320713 29/11/2019 26/11/2019 3/12/2019 71.686 0
UTOMO

9 614 0177A01011190000679 0177r0081119v001556 646746715 WAKIJO 29/11/2019 26/11/2019 3/12/2019 701.306 0

WINDI
10 615 0177A01011190000680 0177r0081119v001577 95129436 29/11/2019 26/11/2019 3/12/2019 34.004 0
YARTI
SITI
11 616 0177A01011190000681 0177r0081119v001509 2042098378 29/11/2019 26/11/2019 3/12/2019 24.524 0
BADRIYAH
ISBANDIYA
12 617 0177A01011190000682 0177r0081119v001508 2219691148 29/11/2019 26/11/2019 3/12/2019 630.524 0
H

13 618 0177A01011190000683 0177r0081119v001596 1034142737 RAJILAH 29/11/2019 26/11/2019 3/12/2019 123.072 0

14 619 0177A01011190000684 0177r0081119v001584 1695084884 SARJIYEM 29/11/2019 26/11/2019 3/12/2019 81.873 0

B.D.Y. ARI
15 620 0177A01011190000685 0177r0081119v001563 1843951713 29/11/2019 26/11/2019 3/12/2019 55.597 0
RATNAWATI
16 621 0177A01011190000686 0177r0081119v001573 648802642 WALDINI 29/11/2019 26/11/2019 3/12/2019 160.861 0

17 622 0177A01011190000687 0177r0081119v001511 94928613 KASILAH 29/11/2019 26/11/2019 3/12/2019 47.134 0

18 623 0177A01011190000688 0177r0081119v001587 94577973 SUBAGYA 29/11/2019 26/11/2019 3/12/2019 5.329 0

19 624 0177A01011190000689 0177r0081119v001576 94696413 PURWOKO 29/11/2019 26/11/2019 3/12/2019 27.968 0

20 625 0177A01011190000690 0177r0081119v001590 648158499 PARTINI 29/11/2019 26/11/2019 3/12/2019 228.308 0

NINUK
21 626 0177A01011190000691 0177r0081119v001572 202540149 29/11/2019 26/11/2019 3/12/2019 20.461 0
KARMINI

22 627 0177A01011190000692 0177r0081119v001592 649100799 UMBUK 29/11/2019 26/11/2019 3/12/2019 49.107 0

EDDY
23 628 0177A01011190000693 0177r0081119v001597 94566723 29/11/2019 26/11/2019 3/12/2019 699.098 0
SUSANTO

24 629 0177A01011190000694 0177r0081119v001589 95413601 GINAH 29/11/2019 26/11/2019 3/12/2019 26.379 0

TAPASASMI
25 630 0177A01011190000695 0177r0081119v001588 95413599 29/11/2019 26/11/2019 3/12/2019 281.847 0
TA

26 631 0177A01011190000696 0177r0081119v001540 646461246 NGATIYEM 29/11/2019 26/11/2019 3/12/2019 10.393 0

MARNO
27 632 0177A01011190000697 0177r0081119v001562 647457693 DIHARJO / 29/11/2019 26/11/2019 3/12/2019 26.584 0
DALIJAN

28 633 0177A01011190000698 0177r0081119v001541 647562521 TUGINEM 29/11/2019 26/11/2019 3/12/2019 9.186 0

SARYATMA
29 634 0177A01011190000699 0177r0081119v001510 649062303 29/11/2019 26/11/2019 3/12/2019 35.387 0
N
 DARYANTO
/ MADIYO
30 635 0177A01011190000700 0177r0081119v001571 649503551 HADI 29/11/2019 26/11/2019 3/12/2019 17.664 0
SUDARMINT
O

31 636 0177A01011190000701 0177r0081119v001568 1699593761 WARTINI 29/11/2019 26/11/2019 3/12/2019 10.922 0

32 637 0177A01011190000702 0177r0081119v001582 647322568 BONIYEM 29/11/2019 26/11/2019 3/12/2019 4.71 0

ASMO
SENTONO,
33 638 0177A01011190000703 0177r0081119v001527 648406427 29/11/2019 26/11/2019 3/12/2019 3.827 0
NY /
SUKILAH
DUTY
34 639 0177A01011190000704 0177r0081119v001558 205913079 FORTUNA, 29/11/2019 26/11/2019 3/12/2019 4.534 0
BA
SUDIYANA,
35 640 0177A01011190000705 0177r0081119v001514 94659568 29/11/2019 26/11/2019 3/12/2019 180.187 0
BCTT

36 641 0177A01011190000706 0177r0081119v001513 1034137473 SATINI 29/11/2019 26/11/2019 3/12/2019 34.931 0

37 642 0177A01011190000707 0177r0081119v001525 647745996 MURYATI 29/11/2019 26/11/2019 3/12/2019 40.009 0

38 643 0177A01011190000708 0177r0081119v001516 1125733645 FAJARI 29/11/2019 26/11/2019 3/12/2019 37.212 0

39 644 0177A01011190000710 0177r0081119v001545 94716674 WAGIMIN 29/11/2019 26/11/2019 3/12/2019 754.415 0

40 645 0177A01011190000711 0177r0081119v001537 95028794 BADRI 29/11/2019 26/11/2019 3/12/2019 424.935 0

41 646 0177A01011190000709 0177r0081119v001524 647347151 SURATMI 29/11/2019 26/11/2019 3/12/2019 67.476 0

 PANgInTEN
42 647 0177A01011190000712 0177r0081119v001515 647728964 PRAPTO 29/11/2019 26/11/2019 3/12/2019 131.609 0
SUDARmO
ROHGIMAN
43 648 0177A01011190000713 0177r0081119v001521 646822978 29/11/2019 26/11/2019 3/12/2019 41.423 0
TO

44 649 0177A01011190000714 0177r0081119v001520 114521128 NGADINEM 29/11/2019 26/11/2019 3/12/2019 175.766 0

45 650 0177A01011190000715 0177r0081119v001519 1034140588 PURWANTI 29/11/2019 26/11/2019 3/12/2019 0 0

ARJO
46 651 0177A01011190000716 0177r0081119v001518 648534058 SUMARTO / 29/11/2019 26/11/2019 3/12/2019 180.466 0
TUKIJO
TRI
47 652 0177A01011190000717 0177r0081119v001512 97288187 WASIYATI, 29/11/2019 26/11/2019 3/12/2019 155.865 0
Dra.

48 653 0177A01011190000718 0177r0081119v001517 649192601 WAGIYO 29/11/2019 26/11/2019 3/12/2019 35.46 0

NY
49 654 0177A01011190000719 0177r0081119v001526 1695079776 29/11/2019 26/11/2019 3/12/2019 50.711 0
RANTIYEM

50 655 0177A01011190000720 0177r0081119v001529 158068304 KASILAN 29/11/2019 26/11/2019 3/12/2019 191.433 0

51 656 0177A01011190000721 0177r0081119v001528 648242324 MARIYAM 29/11/2019 26/11/2019 3/12/2019 173.824 0

52 657 0177A01011190000722 0177r0081119v001531 647918976 MARIYEM 29/11/2019 26/11/2019 3/12/2019 152.351 0

MARTO
53 658 0177A01011190000723 0177r0081119v001532 647480564 29/11/2019 26/11/2019 3/12/2019 137.894 0
SENTONO

54 659 0177A01011190000724 0177r0081119v001535 650221975 ROKHIMIN 29/11/2019 26/11/2019 3/12/2019 52.684 0

SAMSURI /
55 660 0177A01011190000725 0177r0081119v001536 649525634 29/11/2019 26/11/2019 3/12/2019 146.05 0
NGATIMAN
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

1 661 0177A01011190000726 0177r0081119v001646 650929353 PARJILAH 30/11/2019 27/11/2019 4/12/2019 0 0

SITI
2 662 0177A01011190000727 0177r0081119v001634 94852326 PANDANSA 30/11/2019 27/11/2019 4/12/2019 150.703 0
RI

3 663 0177A01011190000728 0177r0081119v001619 95439655 SUBARDI 30/11/2019 27/11/2019 4/12/2019 786.094 0

4 664 0177A01011190000729 0177r0081119v001621 2221951263 MARDINEM 30/11/2019 27/11/2019 4/12/2019 583.56 0

SAKIDJO
5 665 0177A01011190000730 0177r0081119v001628 1261674066 DARTOATM 30/11/2019 27/11/2019 4/12/2019 89.939 0
ODJO

6 666 0177A01011190000731 0177r0081119v001617 647517082 WAGINEM 30/11/2019 27/11/2019 4/12/2019 41.423 0

7 667 0177A01011190000732 0177r0081119v001616 1034126021 TIMBUL 30/11/2019 27/11/2019 4/12/2019 18.253 0

MADIYO
8 668 0177A01011190000733 0177r0081119v001623 647386784 30/11/2019 27/11/2019 4/12/2019 135.025 0
DIHARJO

9 669 0177A01011190000734 0177r0081119v001631 94679166 RUPINGAH 30/11/2019 27/11/2019 4/12/2019 149.114 0

TRIYONO,
10 670 0177A01011190000735 0177r0081119v001630 2047100084 30/11/2019 27/11/2019 4/12/2019 3.003 0
Drs

FLORENTIN
11 671 0177A01011190000736 0177r0081119v001620 95385014 30/11/2019 27/11/2019 4/12/2019 656.085 0
A SUKARTI

12 672 0177A01011190000737 0177r0081119v001609 647458784 KARSINAH 30/11/2019 27/11/2019 4/12/2019 18.253 0

13 673 0177A01011190000738 0177r0081119v001622 646381484 TINI 30/11/2019 27/11/2019 4/12/2019 70.744 0

 SITI
14 674 0177A01011190000739 0177r0081119v001636 97427812 30/11/2019 27/11/2019 4/12/2019 887.242 0
RONDIYAH
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rspBy Tagihan By Verif

1 136 0177A01002200000206 0177r0080220v000380 647634565 MUJIYEM 7/2/2020 5/2/2020 12/2/2020 192.472 0

2 137 0177A01002200000207 0177r0080220v000374 94899598 SUGINEM 7/2/2020 5/2/2020 12/2/2020 53.522 0

3 138 0177A01002200000208 0177r0080220v000326 647939902 NGATINI 7/2/2020 5/2/2020 12/2/2020 300.306 0

4 139 0177A01002200000209 0177r0080220v000375 650837788 URIP WARTIYEM 7/2/2020 5/2/2020 12/2/2020 871.891 0

5 140 0177A01002200000210 0177r0080220v000378 648069039 SAMIYATI 7/2/2020 5/2/2020 12/2/2020 39.596 0

6 141 0177A01002200000211 0177r0080220v000381 1034152659 HADI SUTOPO 7/2/2020 5/2/2020 12/2/2020 104.819 0

7 142 0177A01002200000212 0177r0080220v000357 1100693913 SRI WULANDARI 7/2/2020 5/2/2020 12/2/2020 407.566 0

ASTADI
8 143 0177A01002200000213 0177r0080220v000355 96734924 7/2/2020 5/2/2020 12/2/2020 62.413 0
DARMANA

9 144 0177A01002200000214 0177r0080220v000359 95024338 SUWARTI 7/2/2020 5/2/2020 12/2/2020 348.999 0

10 145 0177A01002200000215 0177r0080220v000352 95088486 LUSIA SUPARSIH 7/2/2020 5/2/2020 12/2/2020 1.145.987 0

11 146 0177A01002200000216 0177r0080220v000365 654494692 UMILAH 7/2/2020 5/2/2020 12/2/2020 720.56 0

12 147 0177A01002200000217 0177r0080220v000356 1034164146 KUATINEM 7/2/2020 5/2/2020 12/2/2020 331.925 0

13 148 0177A01002200000218 0177r0080220v000345 2345347855 KISWANI 7/2/2020 5/2/2020 12/2/2020 9.009 0

14 149 0177A01002200000219 0177r0080220v000362 95121549 MUSMAANIK 7/2/2020 5/2/2020 12/2/2020 159.594 0

B.D.Y. ARI
15 150 0177A01002200000220 0177r0080220v000350 1843951713 7/2/2020 5/2/2020 12/2/2020 55.597 0
RATNAWATI

16 151 0177A01002200000221 0177r0080220v000353 649387012 SUDARMI 7/2/2020 5/2/2020 12/2/2020 70.451 0

17 152 0177A01002200000222 0177r0080220v000324 648907097 RUKIYEM 7/2/2020 5/2/2020 12/2/2020 172.128 0

 ACHROM NUR
18 153 0177A01002200000223 0177r0080220v000354 84074422 7/2/2020 5/2/2020 12/2/2020 474.483 0
MIYATI

19 154 0177A01002200000224 0177r0080220v000373 1458587924 SRI HARYANI 7/2/2020 5/2/2020 12/2/2020 18.96 0

20 155 0177A01002200000225 0177r0080220v000370 1408925531 Sunar Adi Rahmanto 7/2/2020 5/2/2020 12/2/2020 486.347 0

21 156 0177A01002200000226 0177r0080220v000379 94929581 JAMILAH 7/2/2020 5/2/2020 12/2/2020 58.143 0

22 157 0177A01002200000227 0177r0080220v000377 647365724 MARYADI 7/2/2020 5/2/2020 12/2/2020 18.253 0

23 158 0177A01002200000228 0177r0080220v000371 2287018405 NATIRAH 7/2/2020 5/2/2020 12/2/2020 44.102 0

24 159 0177A01002200000229 0177r0080220v000351 2178972336 CESSA RADANA 7/2/2020 5/2/2020 12/2/2020 9.303 0

25 160 0177A01002200000230 0177r0080220v000339 650425869 SUYANTO 7/2/2020 5/2/2020 12/2/2020 20.225 0

BAMBANG
26 161 0177A01002200000231 0177r0080220v000336 1034113623 7/2/2020 5/2/2020 12/2/2020 2.826 0
IRIANTO
 No. By
No. No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Verif
Rx Tagihan

1 162 0177A01002200000232 0177r0080220v000447 1034078973 SARJITO 8/2/2020 6/2/2020 13/02/2020 2.208 0

2 163 0177A01002200000233 0177r0080220v000388 1186357151 ASRI NUFAENI 8/2/2020 6/2/2020 13/02/2020 55.555 0

3 164 0177A01002200000234 0177r0080220v000449 2046907135 MUSTOFA 8/2/2020 6/2/2020 13/02/2020 88.379 0

4 165 0177A01002200000235 0177r0080220v000460 647437634 SUSILAWATI 8/2/2020 6/2/2020 13/02/2020 36.771 0

5 166 0177A01002200000236 0177r0080220v000459 1153935729 SUSTIYATI, Dra. 8/2/2020 6/2/2020 13/02/2020 102.187 0

SUMANTO
6 167 0177A01002200000237 0177r0080220v000445 647739112 8/2/2020 6/2/2020 13/02/2020 163.275 0
SARIMAN

7 168 0177A01002200000238 0177r0080220v000458 205982998 JUMINTEN 8/2/2020 6/2/2020 13/02/2020 64.327 0

ARI
8 169 0177A01002200000239 0177r0080220v000437 1446241195 8/2/2020 6/2/2020 13/02/2020 23.876 0
LISTYONINGSIH

9 170 0177A01002200000240 0177r0080220v000429 649794115 WAGIMAN 8/2/2020 6/2/2020 13/02/2020 570.143 0

10 171 0177A01002200000241 0177r0080220v000448 94870179 SRI SUPRAPTI 8/2/2020 6/2/2020 13/02/2020 772.256 0

11 172 0177A01002200000242 0177r0080220v000454 651063993 SARIYANTI 8/2/2020 6/2/2020 13/02/2020 0 0

12 173 0177A01002200000243 0177r0080220v000384 95157786 SUGIYANTA 8/2/2020 6/2/2020 13/02/2020 51.52 0

13 174 0177A01002200000244 0177r0080220v000456 94904144 NURJIYO 8/2/2020 6/2/2020 13/02/2020 563.901 0

NY. MUGI
14 175 0177A01002200000245 0177r0080220v000453 1034086274 PRAYITNA al. 8/2/2020 6/2/2020 13/02/2020 35.328 0
KAMIYEM
 Y.A.
15 176 0177A01002200000246 0177r0080220v000430 94990713 8/2/2020 6/2/2020 13/02/2020 0 0
SUPRANTONO

16 177 0177A01002200000247 0177r0080220v000446 94762449 SUDILAH 8/2/2020 6/2/2020 13/02/2020 12.1 0

17 178 0177A01002200000248 0177r0080220v000452 94773071 PARJAN 8/2/2020 6/2/2020 13/02/2020 52.08 0

18 179 0177A01002200000249 0177r0080220v000439 1290773788 NGATIJEM 8/2/2020 6/2/2020 13/02/2020 789.156 0

19 180 0177A01002200000250 0177r0080220v000404 2236621893 KARYADI 8/2/2020 6/2/2020 13/02/2020 465.032 0

20 181 0177A01002200000251 0177r0080220v000399 1094369837 MUGIRIYATMI 8/2/2020 6/2/2020 13/02/2020 2.915 0

21 182 0177A01002200000252 0177r0080220v000402 94703512 SUDIYONO 8/2/2020 6/2/2020 13/02/2020 196.904 0

22 183 0177A01002200000253 0177r0080220v000400 648242324 MARIYAM 8/2/2020 6/2/2020 13/02/2020 181.243 0

23 184 0177A01002200000254 0177r0080220v000389 648430255 ERRY SUNARYO 8/2/2020 6/2/2020 13/02/2020 41.423 0

SARTIJO ALIAS
24 185 0177A01002200000255 0177r0080220v000401 1034349074 8/2/2020 6/2/2020 13/02/2020 40.157 0
SARDI SUKEMI

25 186 0177A01002200000256 0177r0080220v000386 95115824 SURATMA 8/2/2020 6/2/2020 13/02/2020 744.76 0

26 187 0177A01002200000257 0177r0080220v000405 2165840785 RUSMINAH 8/2/2020 6/2/2020 13/02/2020 44.661 0

No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif
KATNYO REJO
1 188 0177A01002200000258 0177r0080220v000495 94602745 9/2/2020 7/2/2020 14/02/2020 13.13 0
SUKADI
TRI JAKA
2 189 0177A01002200000259 0177r0080220v000517 96680586 9/2/2020 7/2/2020 14/02/2020 509.221 0
SANTOSA

3 190 0177A01002200000260 0177r0080220v000518 94930244 SUGIJEM 9/2/2020 7/2/2020 14/02/2020 147.318 0

4 191 0177A01002200000261 0177r0080220v000516 94961575 THOHIR HM 9/2/2020 7/2/2020 14/02/2020 54.817 0

5 192 0177A01002200000262 0177r0080220v000510 94871542 MOEDJIJA 9/2/2020 7/2/2020 14/02/2020 8.302 0

6 193 0177A01002200000263 0177r0080220v000499 1034160939 TUMIYATI, NY. 9/2/2020 7/2/2020 14/02/2020 281.847 0

7 194 0177A01002200000264 0177r0080220v000470 95049156 WAGIRAH 9/2/2020 7/2/2020 14/02/2020 97.712 0

8 195 0177A01002200000265 0177r0080220v000469 1034356735 KALIMAH 9/2/2020 7/2/2020 14/02/2020 2.208 0

9 196 0177A01002200000266 0177r0080220v000472 648502896 KAYAT 9/2/2020 7/2/2020 14/02/2020 172.629 0

10 197 0177A01002200000267 0177r0080220v000513 648079931 KAMILAH 9/2/2020 7/2/2020 14/02/2020 37.007 0

11 198 0177A01002200000268 0177r0080220v000514 646295319 PANIYEM 9/2/2020 7/2/2020 14/02/2020 47.84 0

MUJINAH
12 199 0177A01002200000269 0177r0080220v000471 648616645 HARJO 9/2/2020 7/2/2020 14/02/2020 319.413 0
PAWIRO, NY.

13 200 0177A01002200000270 0177r0080220v000508 647381722 SAERI 9/2/2020 7/2/2020 14/02/2020 30.765 0

14 201 0177A01002200000271 0177r0080220v000475 648576786 NGATIRAN 9/2/2020 7/2/2020 14/02/2020 761.099 0

 By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan
Verifikasi

1 487 0177A01002200000204 0177r0080120v001369 97335922 SITI NURYANI 5/2/2020 23/01/2020 30/01/2020 699.098 0

2 488 0177A01001200000547 0177r0080120v001371 94929963 SLAMET 25/01/2020 23/01/2020 30/01/2020 22.257 0

3 489 0177A01001200000548 0177r0080120v001348 95042384 SUTRIYATNO 25/01/2020 23/01/2020 30/01/2020 2.915 0

4 490 0177A01001200000549 0177r0080120v001374 1034604303 GIYANTI 25/01/2020 23/01/2020 30/01/2020 204.895 0

5 491 0177A01001200000550 0177r0080120v001359 2088546906 SAJIYEM 25/01/2020 23/01/2020 30/01/2020 281.859 0

6 492 0177A01001200000551 0177r0080120v001353 649504181 SUPARMI 25/01/2020 23/01/2020 30/01/2020 46.781 0

7 493 0177A01001200000552 0177r0080120v001355 1034555973 SUMARNI 25/01/2020 23/01/2020 30/01/2020 39.244 0

8 494 0177A01001200000553 0177r0080120v001322 1034631988 SUPRIHATIN 25/01/2020 23/01/2020 30/01/2020 45.838 0

9 495 0177A01001200000554 0177r0080120v001370 1034161648 SUTINEM 25/01/2020 23/01/2020 30/01/2020 54.494 0

10 496 0177A01001200000555 0177r0080120v001358 648683627 SARIYEM 25/01/2020 23/01/2020 30/01/2020 67.388 0

11 497 0177A01001200000556 0177r0080120v001329 94690056 SUYITNO 25/01/2020 23/01/2020 30/01/2020 284.566 0

12 498 0177A01001200000557 0177r0080120v001328 96291246 MUDJADI 25/01/2020 23/01/2020 30/01/2020 27.202 0

13 499 0177A01001200000558 0177r0080120v001347 94807135 SAINEM 25/01/2020 23/01/2020 30/01/2020 748.97 0

WAKIYEM
14 500 0177A01001200000559 0177r0080120v001362 1034126842 TARMIDI 25/01/2020 23/01/2020 30/01/2020 18.253 0
UTOMO NY
 ANI SUGIYARTI
15 501 0177A01001200000560 0177r0080120v001346 1529387728 25/01/2020 23/01/2020 30/01/2020 29.97 0
SPD

16 502 0177A01001200000561 0177r0080120v001304 647489709 SUKIYEM 25/01/2020 23/01/2020 30/01/2020 16.751 0

WIDI HARJONO
17 503 0177A01001200000562 0177r0080120v001320 1830857049 25/01/2020 23/01/2020 30/01/2020 453.463 0
A RUWADI

HADI SUTRISNO,
18 504 0177A01001200000563 0177r0080120v001319 647974631 25/01/2020 23/01/2020 30/01/2020 60.72 0
NY. SADINI

19 506 0177A01001200000565 0177r0080120v001323 94691261 SUMIRAH 25/01/2020 23/01/2020 30/01/2020 173.735 0

20 507 0177A01001200000566 0177r0080120v001326 648494109 SUMILAH 25/01/2020 23/01/2020 30/01/2020 91.588 0

21 508 0177A01001200000567 0177r0080120v001317 646975383 KASTINAH 25/01/2020 23/01/2020 30/01/2020 139.82 0

0
RAIHAN DANI
22 509 0177A01001200000568 0177r0080120v001335 646899366 25/01/2020 23/01/2020 30/01/2020 137.35 0
NASRULLOH 0

23 511 0177A01001200000570 0177r0080120v001340 646640559 IZNA SULISTINI 25/01/2020 23/01/2020 30/01/2020 154.376 0
0

24 512 0177A01001200000571 0177r0080120v001305 646598711 MARJONO 25/01/2020 23/01/2020 30/01/2020 2.915 0

0
MUH.
25 513 0177A01001200000572 0177r0080120v001308 2281749737 25/01/2020 23/01/2020 30/01/2020 66.565 0
SAKIRMAN 0
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rspBy Tagihan By Verif
1 33 0177A01012190000073 0177r0081219v000137 648049307 NOVITA 4/12/2019 3/12/2019 10/12/2019 10.922 0
2 34 0177A01012190000074 0177r0081219v000161 648208102 SUKILAH 4/12/2019 3/12/2019 10/12/2019 28.807 0
3 35 0177A01012190000075 0177r0081219v000162 94904414 TUKIYEM 4/12/2019 3/12/2019 10/12/2019 118.98 0
4 36 0177A01012190000076 0177r0081219v000117 94568859 RUSBANI 4/12/2019 3/12/2019 10/12/2019 48.429 0
5 37 0177A01012190000077 0177r0081219v000098 94703512 SUDIYONO 4/12/2019 3/12/2019 10/12/2019 196.904 0
6 38 0177A01012190000078 0177r0081219v000099 649309937 MARJIYATI 4/12/2019 3/12/2019 10/12/2019 51.314 0
7 39 0177A01012190000079 0177r0081219v000102 94949774 M BACHRUN 4/12/2019 3/12/2019 10/12/2019 122.236 0
8 40 0177A01012190000080 0177r0081219v000103 648370304 JINEM 4/12/2019 3/12/2019 10/12/2019 128.996 0
9 41 0177A01012190000081 0177r0081219v000104 647626217 TUKIRAH 4/12/2019 3/12/2019 10/12/2019 493.119 0
10 42 0177A01012190000082 0177r0081219v000106 2236621893 KARYADI 4/12/2019 3/12/2019 10/12/2019 455.405 0
11 43 0177A01012190000083 0177r0081219v000109 647069837 WIRATMI 4/12/2019 3/12/2019 10/12/2019 3.827 0

12
44 0177A01012190000084 0177r0081219v000110 649052695 KIRZIN HASIM 4/12/2019 3/12/2019 10/12/2019 29.705 0
13 45 0177A01012190000085 0177r0081219v000118 649034177 SUGIYEM 4/12/2019 3/12/2019 10/12/2019 18.459 0
14 46 0177A01012190000086 0177r0081219v000082 1034164214 MUJIYEM 4/12/2019 3/12/2019 10/12/2019 214.588 0

15 BAMBANG
47 0177A01012190000087 0177r0081219v000088 96586446 PURWONO 4/12/2019 3/12/2019 10/12/2019 33.297 0
16 48 0177A01012190000088 0177r0081219v000125 647939902 NGATINI 4/12/2019 3/12/2019 10/12/2019 300.306 0
17 49 0177A01012190000089 0177r0081219v000124 650438605 WAKIJAN 4/12/2019 3/12/2019 10/12/2019 137.35 0
18 50 0177A01012190000090 0177r0081219v000155 646550199 KAMILAH 4/12/2019 3/12/2019 10/12/2019 23.7 0
19 51 0177A01012190000091 0177r0081219v000157 654494692 UMILAH 4/12/2019 3/12/2019 10/12/2019 720.56 0

20 MURDI
52 0177A01012190000092 0177r0081219v000159 646940654 WIYONO 4/12/2019 3/12/2019 10/12/2019 23.876 0
21 53 0177A01012190000093 0177r0081219v000080 648096423 BADIYAH 4/12/2019 3/12/2019 10/12/2019 54.2 0
22 54 0177A01012190000094 0177r0081219v000084 1469437659 SUKIJAN 4/12/2019 3/12/2019 10/12/2019 43.807 0
SAHILAH /
23 AMAT
55 0177A01012190000095 0177r0081219v000085 649115919 SAMSUDI, NY 4/12/2019 3/12/2019 10/12/2019 135.908 0
24 56 0177A01012190000096 0177r0081219v000158 648140185 NGATINEM 4/12/2019 3/12/2019 10/12/2019 75.248 0
25 URIP
57 0177A01012190000097 0177r0081219v000151 650837788 WARTIYEM 4/12/2019 3/12/2019 10/12/2019 701.306 0
26 58 0177A01012190000098 0177r0081219v000083 648241424 WATSIRAN 4/12/2019 3/12/2019 10/12/2019 8.126 0
27 59 0177A01012190000099 0177r0081219v000131 647896836 SANATI 4/12/2019 3/12/2019 10/12/2019 42.865 0
28 60 0177A01012190000100 0177r0081219v000081 202558746 SURATNO 4/12/2019 3/12/2019 10/12/2019 18.459 0
29 61 0177A01012190000101 0177r0081219v000154 646972121 NGADENAN 4/12/2019 3/12/2019 10/12/2019 453.463 0

30 TITIK
62 0177A01012190000102 0177r0081219v000146 647611209 WINARSIH 4/12/2019 3/12/2019 10/12/2019 23.052 0

31
63 0177A01012190000103 0177r0081219v000086 1428609328 WIJI WINARTI 4/12/2019 3/12/2019 10/12/2019 19.166 0
32 64 0177A01012190000104 0177r0081219v000152 647643453 SUKIYEM 4/12/2019 3/12/2019 10/12/2019 34.004 0

33
65 0177A01012190000105 0177r0081219v000127 94870179 SRI SUPRAPTI 4/12/2019 3/12/2019 10/12/2019 800.607 0
34 66 0177A01012190000106 0177r0081219v000141 2232133694 SUPARTINI 4/12/2019 3/12/2019 10/12/2019 78.84 0
35 67 0177A01012190000107 0177r0081219v000149 648575166 RUMIYATI 4/12/2019 3/12/2019 10/12/2019 15.544 0
36 68 0177A01012190000108 0177r0081219v000116 647564951 KARTINI 4/12/2019 3/12/2019 10/12/2019 250.032 0
37 69 0177A01012190000109 0177r0081219v000128 1795083153 MUHTAWAR 4/12/2019 3/12/2019 10/12/2019 179.96 0
38 70 0177A01012190000110 0177r0081219v000135 94930277 SUHARJANA 4/12/2019 3/12/2019 10/12/2019 2.208 0

39 SUKINEM / NY.
71 0177A01012190000111 0177r0081219v000147 1034145325 SUDI UTOMO 4/12/2019 3/12/2019 10/12/2019 319.325 0

40 PAINEMMART
72 0177A01012190000112 0177r0081219v000139 647002113 OREJO,NY 4/12/2019 3/12/2019 10/12/2019 18.459 0
41 73 0177A01012190000113 0177r0081219v000129 94663719 BUNIRAH 4/12/2019 3/12/2019 10/12/2019 113.121 0
42 74 0177A01012190000114 0177r0081219v000091 647514876 PARJIYAH 4/12/2019 3/12/2019 10/12/2019 158.858 0
43 75 0177A01012190000115 0177r0081219v000142 648974158 TUJIYEM 4/12/2019 3/12/2019 10/12/2019 78.811 0
44 76 0177A01012190000116 0177r0081219v000122 95049156 WAGIRAH 4/12/2019 3/12/2019 10/12/2019 97.712 0
45 77 0177A01012190000117 0177r0081219v000119 648075789 TUKINEM 4/12/2019 3/12/2019 10/12/2019 34.004 0
46 78 0177A01012190000118 0177r0081219v000113 647461809 SUMARNI 4/12/2019 3/12/2019 10/12/2019 325.017 0
47 79 0177A01012190000119 0177r0081219v000089 649616051 SIYAMMI 4/12/2019 3/12/2019 10/12/2019 2.208 0
48 80 0177A01012190000120 0177r0081219v000090 1034161942 KAMILAH 4/12/2019 3/12/2019 10/12/2019 52.816 0
49 81 0177A01012190000121 0177r0081219v000114 648215559 WAGINAH 4/12/2019 3/12/2019 10/12/2019 49.902 0
50 185 0177A01012190000226 0177r0081219v000172 94904368 DJUMIRAN 12/12/2019 3/12/2019 10/12/2019 740.929 0
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif
BAMBANG
1 82 0177A01012190000122 0177r0081219v000182 1034113623 5/12/2019 4/12/2019 11/12/2019 1.619 0
IRIANTO
2 83 0177A01012190000123 0177r0081219v000169 648048251 WAGILAH 5/12/2019 4/12/2019 11/12/2019 18.96 0
VINANDYA
PELAMONIA
3 84 0177A01012190000124 0177r0081219v000176 2038780978 5/12/2019 4/12/2019 11/12/2019 20.21 0
VIMALA DWI
PURWANTO
LINA AMALIA
4 85 0177A01012190000125 0177r0081219v000189 647031508 5/12/2019 4/12/2019 11/12/2019 31.56 0
HABIBAH
TEGAR
5 86 0177A01012190000126 0177r0081219v000190 647033523 5/12/2019 4/12/2019 11/12/2019 31.56 0
ALFIANSYAH
6 87 0177A01012190000127 0177r0081219v000165 95157786 SUGIYANTA 5/12/2019 4/12/2019 11/12/2019 52.021 0
7 88 0177A01012190000128 0177r0081219v000210 1034310936 SUKARNI 5/12/2019 4/12/2019 11/12/2019 172.629 0
8 89 0177A01012190000129 0177r0081219v000209 95075728 JUMARUDIN 5/12/2019 4/12/2019 11/12/2019 162.156 0
9 90 0177A01012190000130 0177r0081219v000211 94871542 MOEDJIJA 5/12/2019 4/12/2019 11/12/2019 8.302 0
10 91 0177A01012190000131 0177r0081219v000199 94681124 RONDIYAH 5/12/2019 4/12/2019 11/12/2019 436.107 0
YATINEM
11 92 0177A01012190000133 0177r0081219v000200 94691463 PRINGGO 5/12/2019 4/12/2019 11/12/2019 18.253 0
WASONO, NY.
12 93 0177A01012190000134 0177r0081219v000201 85045814 JUWARIYAH 5/12/2019 4/12/2019 11/12/2019 748.823 0

13 94 0177A01012190000135 0177r0081219v000193 94456315 PRIYO ATMOJO 5/12/2019 4/12/2019 11/12/2019 295.605 0

14 95 0177A01012190000136 0177r0081219v000167 648907097 RUKIYEM 5/12/2019 4/12/2019 11/12/2019 172.128 0

LUSIA
15 96 0177A01012190000137 0177r0081219v000196 95088486 5/12/2019 4/12/2019 11/12/2019 1.145.987 0
SUPARSIH
16 97 0177A01012190000138 0177r0081219v000198 1034164146 KUATINEM 5/12/2019 4/12/2019 11/12/2019 297.391 0
17 98 0177A01012190000139 0177r0081219v000168 648047867 NGAJIRAN 5/12/2019 4/12/2019 11/12/2019 7.625
18 99 0177A01012190000132 0177r0081219v000177 1094925352 MUKIJAN 5/12/2019 4/12/2019 11/12/2019 577.738 0
 Tgl. Plynn
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan By Verif
rsp
1 282 0177A01002200000369 0177r0080220v000806 1034299484 KASINAH 14/02/2020 12/2/2020 19/02/2020 6.094 0
2 283 0177A01002200000370 0177r0080220v000773 646782164 SARINEM 14/02/2020 12/2/2020 19/02/2020 26.379 0
3 284 0177A01002200000371 0177r0080220v000796 94592597 SUJATMI 14/02/2020 12/2/2020 19/02/2020 18.253 0
4 285 0177A01002200000372 0177r0080220v000788 1034150376 SUDIYONO 14/02/2020 12/2/2020 19/02/2020 60.735 0
5 286 0177A01002200000373 0177r0080220v000789 646381484 TINI 14/02/2020 12/2/2020 19/02/2020 70.744 0
6 287 0177A01002200000374 0177r0080220v000790 1841840842 ponijah 14/02/2020 12/2/2020 19/02/2020 797.134 0

KROMO
7 SENTONO,NY,
288 0177A01002200000375 0177r0080220v000800 648267309 SIWUH 14/02/2020 12/2/2020 19/02/2020 13.308
8 289 0177A01002200000376 0177r0080220v000792 647515315 SARONO 14/02/2020 12/2/2020 19/02/2020 7.272 0

9 FRANSISKA R.
290 0177A01002200000377 0177r0080220v000802 1808271461 BHASUASTI IVO 14/02/2020 12/2/2020 19/02/2020 652.949 0

10 TEMON BUDI
291 0177A01002200000378 0177r0080220v000771 648903767 SARTONO 14/02/2020 12/2/2020 19/02/2020 36.771 0
11 292 0177A01002200000379 0177r0080220v000770 648393423 WAGILAH 14/02/2020 12/2/2020 19/02/2020 102.717 0
12 293 0177A01002200000380 0177r0080220v000776 1034360583 MARYANTO 14/02/2020 12/2/2020 19/02/2020 653.877 0
13 294 0177A01002200000381 0177r0080220v000782 649387012 SUDARMI 14/02/2020 12/2/2020 19/02/2020 2.826 0
14 295 0177A01002200000382 0177r0080220v000781 648535239 BENIYEM 14/02/2020 12/2/2020 19/02/2020 4.534 0
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. ResepTgl. Plynn rsp
By Tagihan By Verif
AFIFAH
1 296 0177A01002200000353 0177r0080220v000830 1696614243 14/02/2020 13/02/2020 20/02/2020 49.723 0
KHAIRUN NISA
AL AQSHO
2 297 0177A01002200000354 0177r0080220v000841 2444155299 BIHUSNI 14/02/2020 13/02/2020 20/02/2020 20.21 0
WALIDAIN

3 298 0177A01002200000355 0177r0080220v000825 2236620431 TANDIYONO 14/02/2020 13/02/2020 20/02/2020 45.662 0

LATHIFAH
4 299 0177A01002200000356 0177r0080220v000859 647548795 MIFTAKHUL 14/02/2020 13/02/2020 20/02/2020 699.098 0
NA'IM

5 300 0177A01002200000357 0177r0080220v000847 1694247884 MARJINAH 14/02/2020 13/02/2020 20/02/2020 57.35 0

6 301 0177A01002200000358 0177r0080220v000819 94089418 SURATIMAN 14/02/2020 13/02/2020 20/02/2020 673.536 0

MUGIYEM / NY.
7 302 0177A01002200000359 0177r0080220v000855 647756684 14/02/2020 13/02/2020 20/02/2020 288.177 0
NURYANTO

8 303 0177A01002200000360 0177r0080220v000860 94459307 RITNAWATI 14/02/2020 13/02/2020 20/02/2020 23.464 0

9 304 0177A01002200000361 0177r0080220v000854 649546211 RADIYEM 14/02/2020 13/02/2020 20/02/2020 22.698 0

BAMBANG
10 305 0177A01002200000362 0177r0080220v000818 96586446 14/02/2020 13/02/2020 20/02/2020 44.955 0
PURWONO

11 306 0177A01002200000363 0177r0080220v000852 648670678 PAIKEM 14/02/2020 13/02/2020 20/02/2020 18.253 0

12 307 0177A01002200000364 0177r0080220v000868 69480944 LUKITAS TUTI 14/02/2020 13/02/2020 20/02/2020 124.943 0

13 308 0177A01002200000365 0177r0080220v000864 94574362 WARTINI, S.IP 14/02/2020 13/02/2020 20/02/2020 46.692 0

14 309 0177A01002200000366 0177r0080220v000865 94905437 MURDINEM 14/02/2020 13/02/2020 20/02/2020 392.2 0

15 310 0177A01002200000367 0177r0080220v000867 94955433 NGADIYEM 14/02/2020 13/02/2020 20/02/2020 24.583 0

16 311 0177A01002200000368 0177r0080220v000853 1281030603 SUKIJO 14/02/2020 13/02/2020 20/02/2020 18.253 0

No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp
By Tagihan
By Verifikasi
GIFA
NANDA
1 129 0177A01012190000170 0177r0081219v000363 647816062 FEBRI 8/12/2019 7/12/2019 14/12/2019 137.35 0
KURNIAWA
N

2 130 0177A01012190000171 0177r0081219v000374 648627467 SARJONO 8/12/2019 7/12/2019 14/12/2019 32.163 0

3 131 0177A01012190000172 0177r0081219v000375 94931392 WASIK 8/12/2019 7/12/2019 14/12/2019 36.888 0

4 132 0177A01012190000173 0177r0081219v000349 97250613 WAGIYEM 8/12/2019 7/12/2019 14/12/2019 24.082 0

IBNU
5 133 0177A01012190000174 0177r0081219v000351 94812085 PRAYITNO 8/12/2019 7/12/2019 14/12/2019 118.98 0
SUTOPO

6 134 0177A01012190000175 0177r0081219v000350 1819382872 ISTINAH 8/12/2019 7/12/2019 14/12/2019 56.643 0

7 135 0177A01012190000176 0177r0081219v000381 1290773788 NGATIJEM 8/12/2019 7/12/2019 14/12/2019 649.337 0

8 136 0177A01012190000177 0177r0081219v000346 648502896 KAYAT 8/12/2019 7/12/2019 14/12/2019 155.603 0

H.
9 137 0177A01012190000178 0177r0081219v000361 95131361 8/12/2019 7/12/2019 14/12/2019 32.531 0
SUTARNO

SURINI
10 138 0177A01012190000179 0177r0081219v000362 95131359 8/12/2019 7/12/2019 14/12/2019 23.876 0
TURSIHATI

11 139 0177A01012190000180 0177r0081219v000345 1034356735 KALIMAH 8/12/2019 7/12/2019 14/12/2019 2.208 0

12 140 0177A01012190000181 0177r0081219v000389 648786082 SUHARDI 8/12/2019 7/12/2019 14/12/2019 73.85 0

13 141 0177A01012190000182 0177r0081219v000386 94904144 NURJIYO 8/12/2019 7/12/2019 14/12/2019 563.901 0

NY. MUGI
PRAYITNA
14 142 0177A01012190000183 0177r0081219v000383 1034086274 8/12/2019 7/12/2019 14/12/2019 35.328
AL.
KAMIYEM

15 143 0177A01012190000184 0177r0081219v000390 648231344 MUJIYATI 8/12/2019 7/12/2019 14/12/2019 18.459 0

16 144 0177A01012190000185 0177r0081219v000395 648079931 KAMILAH 8/12/2019 7/12/2019 14/12/2019 37.007 0

17 145 0177A01012190000186 0177r0081219v000379 649794115 WAGIMAN 8/12/2019 7/12/2019 14/12/2019 427.084 0

MUJINAH
HARJO
18 146 0177A01012190000187 0177r0081219v000347 648616645 8/12/2019 7/12/2019 14/12/2019 599.053 0
PAWIRO,
NY.

19 147 0177A01012190000188 0177r0081219v000385 94568747 PRABAWA 8/12/2019 7/12/2019 14/12/2019 719.735 0

20 148 0177A01012190000189 0177r0081219v000388 205982998 JUMINTEN 8/12/2019 7/12/2019 14/12/2019 64.828 0

YULI
21 149 0177A01012190000190 0177r0081219v000384 648214773 WULANDAR 8/12/2019 7/12/2019 14/12/2019 44.043 0
I

22 150 0177A01012190000191 0177r0081219v000391 647634565 MUJIYEM 8/12/2019 7/12/2019 14/12/2019 53.64 0

23 151 0177A01012190000192 0177r0081219v000348 648576786 NGATIRAN 8/12/2019 7/12/2019 14/12/2019 761.099 0

24 152 0177A01012190000193 0177r0081219v000352 648919934 TEGUH 8/12/2019 7/12/2019 14/12/2019 19.254 0

25 153 0177A01012190000194 0177r0081219v000397 94691261 SUMIRAH 8/12/2019 7/12/2019 14/12/2019 347.45

fikasi
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

1 312 0177A01002200000383 0177r0080220v000899 648991541 SUGIMAN 15/02/2020 14/02/2020 21/02/2020 6.918 0

2 313 0177A01002200000384 0177r0080220v000909 648162077 RUBIYEM 15/02/2020 14/02/2020 21/02/2020 26.128 0

SUKO
3 314 0177A01002200000385 0177r0080220v000910 647378177 DIKARYONO 15/02/2020 14/02/2020 21/02/2020 7.625 0
SAKIYO

4 315 0177A01002200000386 0177r0080220v000886 649532103 MUFTI ARIFIN 15/02/2020 14/02/2020 21/02/2020 5.476 0

5 316 0177A01002200000387 0177r0080220v000948 95049742 SITI WASILAH 15/02/2020 14/02/2020 21/02/2020 825.868 0

SITI
6 317 0177A01002200000388 0177r0080220v000889 95120289 MULANTINI 15/02/2020 14/02/2020 21/02/2020 159.263 0
HANIFAH

7 318 0177A01002200000389 0177r0080220v000888 95120278 MULYADI 15/02/2020 14/02/2020 21/02/2020 30.765 0

BUDI UTOMO /
8 319 0177A01002200000390 0177r0080220v000890 648178031 15/02/2020 14/02/2020 21/02/2020 18.253 0
WAKIJO
ASIS
9 320 0177A01002200000391 0177r0080220v000947 1261932456 15/02/2020 14/02/2020 21/02/2020 6.006 0
NURMANTO

10 321 0177A01002200000392 0177r0080220v000946 1261932884 SUPRAPTINI 15/02/2020 14/02/2020 21/02/2020 2.208 0

11 322 0177A01002200000393 0177r0080220v000945 651197226 PARINEM 15/02/2020 14/02/2020 21/02/2020 23.111 0

12 323 0177A01002200000394 0177r0080220v000950 648893867 SANIYAH 15/02/2020 14/02/2020 21/02/2020 3.827 0

13 324 0177A01002200000395 0177r0080220v000883 647894856 SAMIYEM 15/02/2020 14/02/2020 21/02/2020 52.492 0

14 325 0177A01002200000396 0177r0080220v000891 95047918 SARTOYO 15/02/2020 14/02/2020 21/02/2020 172.629 0

15 326 0177A01002200000397 0177r0080220v000922 1277303725 Y. SUWARNIATI 15/02/2020 14/02/2020 21/02/2020 149.083 0

16 327 0177A01002200000398 0177r0080220v000931 651822265 SURATMI 15/02/2020 14/02/2020 21/02/2020 77.133 0

17 328 0177A01002200000399 0177r0080220v000933 649878445 NGADINEM 15/02/2020 14/02/2020 21/02/2020 32.973 0

18 329 0177A01002200000400 0177r0080220v000932 649282623 NGADIYEM 15/02/2020 14/02/2020 21/02/2020 281.847 0

19 330 0177A01002200000401 0177r0080220v000935 649337949 TUGINEM 15/02/2020 14/02/2020 21/02/2020 2.208 0

20 331 0177A01002200000402 0177r0080220v000939 651076075 SUMINEM 15/02/2020 14/02/2020 21/02/2020 11.453 0

21 332 0177A01002200000403 0177r0080220v000938 1034146427 SUDARTO 15/02/2020 14/02/2020 21/02/2020 8.214 0

22 333 0177A01002200000404 0177r0080220v000893 647516643 NGADIKEM 15/02/2020 14/02/2020 21/02/2020 37.243 0

23 334 0177A01002200000405 0177r0080220v000941 1695086684 JUMANAH 15/02/2020 14/02/2020 21/02/2020 732.954 0

24 335 0177A01002200000406 0177r0080220v000934 649337308 AGAN SURYADI 15/02/2020 14/02/2020 21/02/2020 24.612 0

25 336 0177A01002200000407 0177r0080220v000943 649086401 JUMINTEN 15/02/2020 14/02/2020 21/02/2020 453.463 0

26 337 0177A01002200000408 0177r0080220v000942 1696766657 WARDANAH 15/02/2020 14/02/2020 21/02/2020 592.252 0

AZKA FIKRI
27 338 0177A01002200000409 0177r0080220v000925 1383905643 15/02/2020 14/02/2020 21/02/2020 40.42 0
YUDISTIRA
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. ResepTgl. Plynn rspBy Tagihan By Verif
PARJIYANTO .
1 408 0177A01002200000479 0177r0080220v001248 2462725181 19/02/2020 18/02/2020 25/02/2020 321.621 0
MARSUDI HADI. S
2 409 0177A01002200000480 0177r0080220v001232 646923071 PAINAH 19/02/2020 18/02/2020 25/02/2020 16.207 0
3 410 0177A01002200000481 0177r0080220v001227 1812039017 WADIYATI 19/02/2020 18/02/2020 25/02/2020 160.713 0
4 411 0177A01002200000482 0177r0080220v001178 2177776719 SUTILAH 19/02/2020 18/02/2020 25/02/2020 49.077 0
5 412 0177A01002200000483 0177r0080220v001252 647560629 MARINAH 19/02/2020 18/02/2020 25/02/2020 167.759 0
6 413 0177A01002200000484 0177r0080220v001261 2376520244 IRIANI 19/02/2020 18/02/2020 25/02/2020 34.004 0
7 414 0177A01002200000485 0177r0080220v001193 1034131465 WIDODO 19/02/2020 18/02/2020 25/02/2020 419.459 0
8 415 0177A01002200000500 0177r0080220v001220 94582528 SURYANTI 24/02/2020 18/02/2020 25/02/2020 767.34 0
9 416 0177A01002200000487 0177r0080220v001262 647833724 ATMO DIMEJO, NY 19/02/2020 18/02/2020 25/02/2020 67.771 0

10 417 0177A01002200000488 0177r0080220v001221 94582517 UNTUNG SUBAGYO 19/02/2020 18/02/2020 25/02/2020 578.865 0

11 418 0177A01002200000522 0177r0080220v001162 1662151432 H. SUBARDI 26/02/2020 18/02/2020 25/02/2020 242.275 0

12 419 0177A01002200000490 0177r0080220v001170 94891779 HALLY SOEROSO 19/02/2020 18/02/2020 25/02/2020 357.087 0
13 420 0177A01002200000491 0177r0080220v001165 1034138902 M. NOOR HADI 19/02/2020 18/02/2020 25/02/2020 6.124 0
14 421 0177A01002200000492 0177r0080220v001168 2456796947 TIJEM 19/02/2020 18/02/2020 25/02/2020 17.546 0

15 422 0177A01002200000493 0177r0080220v001172 648441505 SUBANDI RAHARJO 19/02/2020 18/02/2020 25/02/2020 158.279 0

16 423 0177A01002200000494 0177r0080220v001173 651386259 MARJOWIYONO 19/02/2020 18/02/2020 25/02/2020 14.161 0

17 424 0177A01002200000495 0177r0080220v001169 95027793 SURAJI 19/02/2020 18/02/2020 25/02/2020 55.495 0
18 425 0177A01002200000496 0177r0080220v001188 648233774 WATIYEM 19/02/2020 18/02/2020 25/02/2020 53.522 0
H.CHOFIF
19 426 0177A01002200000497 0177r0080220v001234 94923797 19/02/2020 18/02/2020 25/02/2020 3.827 0
MUSYAFA`.BA

20 427 0177A01002200000498 0177r0080220v001237 646598946 SRI HIDAYATI, S.PD. I 19/02/2020 18/02/2020 25/02/2020 10.922 0

21 428 0177A01002200000499 0177r0080220v001236 646405356 SUTIMIN 19/02/2020 18/02/2020 25/02/2020 6.83 0

No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif
MUHAMMAD
1 429 0177A01002200000501 0177r0080220v001314 2066127726 ARINDRA 25/02/2020 19/02/2020 26/02/2020 72.765 0
WIRADITYA

2 430 0177A01002200000502 0177r0080220v001324 655950969 MULYADI 25/02/2020 19/02/2020 26/02/2020 215.095 0

3 431 0177A01002200000503 0177r0080220v001330 1458639123 MUJI TENTREM 25/02/2020 19/02/2020 26/02/2020 106.881 0

4 432 0177A01002200000504 0177r0080220v001295 95131361 H. SUTARNO 25/02/2020 19/02/2020 26/02/2020 29.587 0

SUMARJO
5 433 0177A01002200000505 0177r0080220v001331 646732326 25/02/2020 19/02/2020 26/02/2020 62.766 0
HARTONO, NY.

6 434 0177A01002200000506 0177r0080220v001335 95068899 SUBUR SUTOTO 25/02/2020 19/02/2020 26/02/2020 34.004 0

7 435 0177A01002200000507 0177r0080220v001348 1034132433 PONIRAH 25/02/2020 19/02/2020 26/02/2020 79.165 0

8 436 0177A01002200000508 0177r0080220v001345 1858700428 ZUMAROH 25/02/2020 19/02/2020 26/02/2020 561.487 0

9 437 0177A01002200000509 0177r0080220v001332 648027281 KISMARTAYA 25/02/2020 19/02/2020 26/02/2020 738.872 0

10 438 0177A01002200000510 0177r0080220v001273 647564951 KARTINI 25/02/2020 19/02/2020 26/02/2020 283.034 0

11 439 0177A01002200000511 0177r0080220v001274 649078479 TUKIMAN 25/02/2020 19/02/2020 26/02/2020 702.16 0

12 440 0177A01002200000512 0177r0080220v001275 1820155307 KAMILAH 25/02/2020 19/02/2020 26/02/2020 2.208 0

SITI ZAHROH,
13 441 0177A01002200000513 0177r0080220v001339 95106532 25/02/2020 19/02/2020 26/02/2020 45.662 0
B.A.
 HADI KISWOYO,
14 442 0177A01002200000514 0177r0080220v001342 648238342 25/02/2020 19/02/2020 26/02/2020 85.407 0
NY / KOSINAH

15 443 0177A01002200000515 0177r0080220v001350 647846008 WAKIYEM 25/02/2020 19/02/2020 26/02/2020 18.96 0

16 444 0177A01002200000516 0177r0080220v001352 94808406 SAJEM 25/02/2020 19/02/2020 26/02/2020 20.667 0

17 445 0177A01002200000517 0177r0080220v001354 649095309 SUKIMAN 25/02/2020 19/02/2020 26/02/2020 11.6 0

18 446 0177A01002200000518 0177r0080220v001351 1696771113 SARJIYEM 25/02/2020 19/02/2020 26/02/2020 603.107 0

19 447 0177A01002200000519 0177r0080220v001336 648658001 NGAPIDAH 25/02/2020 19/02/2020 26/02/2020 35.77 0

SURINI
20 448 0177A01002200000520 0177r0080220v001296 95131359 25/02/2020 19/02/2020 26/02/2020 23.876 0
TURSIHATI

21 449 0177A01002200000521 0177r0080220v001347 94958796 SUDADI 25/02/2020 19/02/2020 26/02/2020 487.29 0

Verif
 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Verif
rsp Tagihan
KROMO
1 211 0177A01012190000252 0177r0081219v000653 648267309 SENTONO,N 13/12/2019 12/12/2019 19/12/2019 13.308 0
Y, SIWUH
2 212 0177A01012190000253 0177r0081219v000662 649086401 JUMINTEN 13/12/2019 12/12/2019 19/12/2019 452.756 0
3 213 0177A01012190000254 0177r0081219v000656 94930852 SUTILAH 13/12/2019 12/12/2019 19/12/2019 12.012 0
SITI
4 214 0177A01012190000255 0177r0081219v000655 97335922 13/12/2019 12/12/2019 19/12/2019 853.474 0
NURYANI

TEMON BUDI
5 215 0177A01012190000256 0177r0081219v000599 648903767 13/12/2019 12/12/2019 19/12/2019 36.771 0
SARTONO

6 216 0177A01012190000257 0177r0081219v000651 95520813 SUPRIHATIN 13/12/2019 12/12/2019 19/12/2019 15.457 0

7 217 0177A01012190000258 0177r0081219v000644 95610014 SARJILAH 13/12/2019 12/12/2019 19/12/2019 724.152 0

8 218 0177A01012190000259 0177r0081219v000648 1034130633 DANUN 13/12/2019 12/12/2019 19/12/2019 656.792 0
9 219 0177A01012190000260 0177r0081219v000649 94905437 MURDINEM 13/12/2019 12/12/2019 19/12/2019 611.44 0
10 220 0177A01012190000261 0177r0081219v000645 94556013 SUKINEM 13/12/2019 12/12/2019 19/12/2019 30.765 0
MUFTI
11 221 0177A01012190000262 0177r0081219v000600 649532103 13/12/2019 12/12/2019 19/12/2019 5.476 0
ARIFIN
12 222 0177A01012190000263 0177r0081219v000639 1841840842 ponijah 13/12/2019 12/12/2019 19/12/2019 794.072 0
13 223 0177A01012190000264 0177r0081219v000640 1139621681 SUTARTO 13/12/2019 12/12/2019 19/12/2019 14.044 0
WAKIDIN
14 224 0177A01012190000265 0177r0081219v000601 647945133 TARUNO 13/12/2019 12/12/2019 19/12/2019 75.101 0
Wiyono
HADI
PRASETYO /
15 225 0177A01012190000266 0177r0081219v000642 647413907 13/12/2019 12/12/2019 19/12/2019 71.451 0
YATIN
WIYONO
16 226 0177A01012190000267 0177r0081219v000647 94958796 SUDADI 13/12/2019 12/12/2019 19/12/2019 486.642 0
17 227 0177A01012190000268 0177r0081219v000602 646782164 SARINEM 13/12/2019 12/12/2019 19/12/2019 26.379 0
18 228 0177A01012190000269 0177r0081219v000646 647844579 DALINEM 13/12/2019 12/12/2019 19/12/2019 142.028 0
19 229 0177A01012190000270 0177r0081219v000643 1034838797 WATIKEM 13/12/2019 12/12/2019 19/12/2019 38.92 0
PAIT
20 230 0177A01012190000271 0177r0081219v000661 94697111 PROJOMURS 13/12/2019 12/12/2019 19/12/2019 951.396 0
AHID
21 231 0177A01012190000272 0177r0081219v000597 647894856 SAMIYEM 13/12/2019 12/12/2019 19/12/2019 52.492 0
22 232 0177A01012190000273 0177r0081219v000598 648393423 WAGILAH 13/12/2019 12/12/2019 19/12/2019 102.717 0
SAMSI
23 233 0177A01012190000274 0177r0081219v000652 648255532 13/12/2019 12/12/2019 19/12/2019 335.339 0
ASTINA
SUDARMAN
24 234 0177A01012190000275 0177r0081219v000660 648038564 13/12/2019 12/12/2019 19/12/2019 19.342 0
TO
25 235 0177A01012190000276 0177r0081219v000659 94592597 SUJATMI 13/12/2019 12/12/2019 19/12/2019 18.253 0
26 236 0177A01012190000277 0177r0081219v000615 2280526784 SAINI 13/12/2019 12/12/2019 19/12/2019 471.685 0
27 237 0177A01012190000278 0177r0081219v000595 647489709 SUKIYEM 13/12/2019 12/12/2019 19/12/2019 22.875 0
OSKAR
28 239 0177A01012190000280 0177r0081219v000608 94682114 13/12/2019 12/12/2019 19/12/2019 2.208 0
RESSI
YULI
29 240 0177A01012190000281 0177r0081219v000594 97607834 SULISTYAW 13/12/2019 12/12/2019 19/12/2019 41.009 0
ATI
30 241 0177A01012190000282 0177r0081219v000613 647694404 TEGUH 13/12/2019 12/12/2019 19/12/2019 299.305 0
31 242 0177A01012190000283 0177r0081219v000593 1696608652 JUMINTEN 13/12/2019 12/12/2019 19/12/2019 219.24 0
32 243 0177A01012190000284 0177r0081219v000616 1090048509 PONIJEM 13/12/2019 12/12/2019 19/12/2019 2.915 0
33 244 0177A01012190000285 0177r0081219v000607 95027793 SURAJI 13/12/2019 12/12/2019 19/12/2019 33.562 0
TUKIDJO
ABADI .
34 245 0177A01012190000286 0177r0081219v000596 94696784 13/12/2019 12/12/2019 19/12/2019 4.122 0
HADI
PRASETYO
35 246 0177A01012190000287 0177r0081219v000617 647996185 SALJO 13/12/2019 12/12/2019 19/12/2019 196.952 0
36 247 0177A01012190000288 0177r0081219v000604 1034146203 PARINEM 13/12/2019 12/12/2019 19/12/2019 25.348 0
37 248 0177A01012190000289 0177r0081219v000618 650642049 MASANAH 13/12/2019 12/12/2019 19/12/2019 279.639 0
38 249 0177A01012190000290 0177r0081219v000606 1034334314 DASUMI 13/12/2019 12/12/2019 19/12/2019 485.611 0
 RAHMAT
39 250 0177A01012190000291 0177r0081219v000610 1696639779 13/12/2019 12/12/2019 19/12/2019 59.497 0
SALAM
40 251 0177A01012190000292 0177r0081219v000611 647835131 TRI UTAMI 13/12/2019 12/12/2019 19/12/2019 35.211 0
41 252 0177A01012190000293 0177r0081219v000612 647834905 JUMALI 13/12/2019 12/12/2019 19/12/2019 143.058 0
 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Verif
rsp Tagihan
RUSDIYAN
1 450 0177A01002200000523 0177r0080220v001410 1102952823 26/02/2020 20/02/2020 27/02/2020 3.062 0
TA

2 451 0177A01002200000524 0177r0080220v001364 1696786828 SUGIARTO 26/02/2020 20/02/2020 27/02/2020 30.677 0

3 452 0177A01002200000525 0177r0080220v001422 94906563 SATIJO 26/02/2020 20/02/2020 27/02/2020 2.915 0

4 453 0177A01002200000526 0177r0080220v001414 647180717 YATINI 26/02/2020 20/02/2020 27/02/2020 27.232 0

5 454 0177A01002200000527 0177r0080220v001360 1876177912 WALIDAH 26/02/2020 20/02/2020 27/02/2020 35.269 0

ASIH BUDI
6 455 0177A01002200000528 0177r0080220v001361 1650925427 26/02/2020 20/02/2020 27/02/2020 139.82 0
RAHAYU

7 456 0177A01002200000529 0177r0080220v001400 1034319071 WARIJEM 26/02/2020 20/02/2020 27/02/2020 479.34 0

HERY
8 457 0177A01002200000530 0177r0080220v001407 647849463 26/02/2020 20/02/2020 27/02/2020 2.208 0
KRISTIANI

9 458 0177A01002200000531 0177r0080220v001415 1435523095 KAMILAH 26/02/2020 20/02/2020 27/02/2020 42.394 0

MUGIYANT
10 459 0177A01002200000532 0177r0080220v001413 1034134874 26/02/2020 20/02/2020 27/02/2020 729.863 0
I

11 460 0177A01002200000533 0177r0080220v001421 1096263044 SUBARDI 26/02/2020 20/02/2020 27/02/2020 36.859 0

JOYO
12 461 0177A01002200000534 0177r0080220v001405 647218394 SUDARMO, 26/02/2020 20/02/2020 27/02/2020 56.083 0
NY. / TIJAH
 UDI
13 462 0177A01002200000535 0177r0080220v001417 2346696369 26/02/2020 20/02/2020 27/02/2020 2.915 0
SUSANTO

14 463 0177A01002200000536 0177r0080220v001408 1034136843 ASIHONO 26/02/2020 20/02/2020 27/02/2020 12.276 0

ADI
WIYONO,
15 464 0177A01002200000537 0177r0080220v001420 647628423 26/02/2020 20/02/2020 27/02/2020 2.208 0
NY. /
MUJINEM
SRI
16 465 0177A01002200000538 0177r0080220v001386 95060632 26/02/2020 20/02/2020 27/02/2020 19.137 0
HARYANI
SITI
17 466 0177A01002200000539 0177r0080220v001419 647812001 26/02/2020 20/02/2020 27/02/2020 2.208 0
MU'INAH

18 467 0177A01002200000540 0177r0080220v001365 647502028 PANIYEM 26/02/2020 20/02/2020 27/02/2020 180.863 0

19 468 0177A01002200000541 0177r0080220v001416 647698656 WARSIYEM 26/02/2020 20/02/2020 27/02/2020 16.222 0

WAGIYONO
20 469 0177A01002200000542 0177r0080220v001411 648512627 / WARDI 26/02/2020 20/02/2020 27/02/2020 16.353 0
WIYONO
HJ.
21 470 0177A01002200000543 0177r0080220v001401 103844564 DJUWITOS 26/02/2020 20/02/2020 27/02/2020 333.544 0
ARI

22 471 0177A01002200000544 0177r0080220v001409 95035149 BADRIYAH 26/02/2020 20/02/2020 27/02/2020 38.096 0

DJUMINTE
23 472 0177A01002200000545 0177r0080220v001404 2749709518 26/02/2020 20/02/2020 27/02/2020 468.477 0
N
DWI
24 473 0177A01002200000546 0177r0080220v001378 2699509678 26/02/2020 20/02/2020 27/02/2020 23.464 0
SURYANI

JONET
25 474 0177A01002200000547 0177r0080220v001379 648934457 26/02/2020 20/02/2020 27/02/2020 88.409 0
DASWORO
26 475 0177A01002200000548 0177r0080220v001380 1090048509 PONIJEM 26/02/2020 20/02/2020 27/02/2020 2.915 0

27 476 0177A01002200000549 0177r0080220v001357 647324695 KAMIDJO 26/02/2020 20/02/2020 27/02/2020 2.915 0

28 477 0177A01002200000550 0177r0080220v001382 648969849 PAINAH 26/02/2020 20/02/2020 27/02/2020 147.891 0

No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

1
0 0177A01012190000332 0177r0081219v000764 650671784 SAMIRAH 15/12/2019 14/12/2019 21/12/2019 0 0

2
282 0177A01012190000333 0177r0081219v000764 650671784 SAMIRAH 15/12/2019 14/12/2019 21/12/2019 31.089 0
SURATINEM
3 DWI SUWARSO
283 0177A01012190000324 0177r0081219v000751 646454384 NY 15/12/2019 14/12/2019 21/12/2019 165.836 0

4
284 0177A01012190000325 0177r0081219v000779 647063267 PONILAH 15/12/2019 14/12/2019 21/12/2019 11.6 0

5
285 0177A01012190000326 0177r0081219v000752 647562521 TUGINEM 15/12/2019 14/12/2019 21/12/2019

6 MUGIYEM / NY.
286 0177A01012190000327 0177r0081219v000777 647756684 NURYANTO 15/12/2019 14/12/2019 21/12/2019 427.172 0
SITI
7 MULANTINI
287 0177A01012190000328 0177r0081219v000768 95120289 HANIFAH 15/12/2019 14/12/2019 21/12/2019 127.377 0

8
288 0177A01012190000329 0177r0081219v000767 95120278 MULYADI 15/12/2019 14/12/2019 21/12/2019 1.619 0

9
289 0177A01012190000330 0177r0081219v000761 1034299484 KASINAH 15/12/2019 14/12/2019 21/12/2019 5.123 0

10
290 0177A01012190000331 0177r0081219v000749 2461986393 DWIJO WIYONO 15/12/2019 14/12/2019 21/12/2019 84.11 0
Verif
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

1 RAIHAN DANI
291 0177A01012190000334 0177r0081219v000843 646899366 NASRULLOH 17/12/2019 16/12/2019 23/12/2019 137.35 0

2
292 0177A01012190000335 0177r0081219v000837 85851358 KAMARI 17/12/2019 16/12/2019 23/12/2019 67.772 0

3
293 0177A01012190000336 0177r0081219v000854 1034150567 PURWANTO 17/12/2019 16/12/2019 23/12/2019 590.044 0

4
294 0177A01012190000337 0177r0081219v000846 1894527191 tugirah 17/12/2019 16/12/2019 23/12/2019 36.712 0

5 SUWADI
295 0177A01012190000338 0177r0081219v000845 652090386 WIJAYA 17/12/2019 16/12/2019 23/12/2019 23.052 0

6
296 0177A01012190000339 0177r0081219v000805 649249852 DASINEM 17/12/2019 16/12/2019 23/12/2019 8.567 0

7
297 0177A01012190000340 0177r0081219v000841 649337308 AGAN SURYADI 17/12/2019 16/12/2019 23/12/2019 22.198 0

8
298 0177A01012190000341 0177r0081219v000842 649337949 TUGINEM 17/12/2019 16/12/2019 23/12/2019 2.208 0
JOYO
9 SUDARMO, NY. /
299 0177A01012190000342 0177r0081219v000833 647218394 TIJAH 17/12/2019 16/12/2019 23/12/2019 56.083 0

10
300 0177A01012190000343 0177r0081219v000832 94954127 RAMINI 17/12/2019 16/12/2019 23/12/2019 44.22 0
SETYO
11 HARJONO /
301 0177A01012190000344 0177r0081219v000829 647563149 JOKERTO 17/12/2019 16/12/2019 23/12/2019 0 0

12 JUWARNI
302 0177A01012190000345 0177r0081219v000836 94491382 PURNOMO 17/12/2019 16/12/2019 23/12/2019 23.758 0

13
303 0177A01012190000346 0177r0081219v000839 649538504 KARJIYEM 17/12/2019 16/12/2019 23/12/2019 34.474 0

14
304 0177A01012190000347 0177r0081219v000844 1125829214 RAMISIH 17/12/2019 16/12/2019 23/12/2019 47.812 0
Verif
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif
Column1Column2 Column3 Column4 Column5 Column6 Column7 Column8 Column9 Column10 Column11
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

1 319 0177A01012190000362 0177r0081219v000916 648741644 SAMIYEM 18/12/2019 18/12/2019 25/12/2019 7.625 0

VERONIKA
2 320 0177A01012190000363 0177r0081219v000992 1696604793 RELIKA 18/12/2019 18/12/2019 25/12/2019 24.583 0
DIHANTARI
ENDAR
3 321 0177A01012190000364 0177r0081219v000979 94575159 18/12/2019 18/12/2019 25/12/2019 33.297 0
SRIHARTI
CAHYA
4 322 0177A01012190000365 0177r0081219v000984 1150986339 18/12/2019 18/12/2019 25/12/2019 18.194 0
PRIHANTARA

5 323 0177A01012190000366 0177r0081219v000922 2633169723 SUDILAH 18/12/2019 18/12/2019 25/12/2019 50.637

RISMI
6 324 0177A01012190000367 0177r0081219v000943 1787273245 18/12/2019 18/12/2019 25/12/2019 3.003 0
NARWATI, S.PD.

7 325 0177A01012190000368 0177r0081219v000986 648640045 PRIYO UTOMO 18/12/2019 18/12/2019 25/12/2019 8.538 0

8 326 0177A01012190000369 0177r0081219v000982 647248217 WAFINGAH 18/12/2019 18/12/2019 25/12/2019 38.595 0

9 327 0177A01012190000370 0177r0081219v000974 1858700428 ZUMAROH 18/12/2019 18/12/2019 25/12/2019 701.306 0

ADI SUMARTO /
10 328 0177A01012190000371 0177r0081219v000978 646570405 18/12/2019 18/12/2019 25/12/2019 11.6 0
MUJIYONO

11 329 0177A01012190000372 0177r0081219v000990 95095855 TUMISAH 18/12/2019 18/12/2019 25/12/2019 909.624 0

12 330 0177A01012190000373 0177r0081219v000965 97724035 JAPIRIN, BA 18/12/2019 18/12/2019 25/12/2019 361.892 0

13 331 0177A01012190000374 0177r0081219v000925 648933322 SUMARTINI 18/12/2019 18/12/2019 25/12/2019 41.305 0

14 332 0177A01012190000375 0177r0081219v000928 1454069799 PARDINI 18/12/2019 18/12/2019 25/12/2019 732.071 0

15 333 0177A01012190000376 0177r0081219v000929 647387065 MUJINAH 18/12/2019 18/12/2019 25/12/2019 450.224 0

NGATIJAN
16 334 0177A01012190000377 0177r0081219v000967 648559192 SISWO 18/12/2019 18/12/2019 25/12/2019 425.583 0
SUMARTO

17 335 0177A01012190000378 0177r0081219v000927 647731754 AG DARYANTA 18/12/2019 18/12/2019 25/12/2019 752.09 0

18 336 0177A01012190000379 0177r0081219v000924 647322524 NGATINI 18/12/2019 18/12/2019 25/12/2019 139.82 0

19 337 0177A01012190000380 0177r0081219v000973 94860731 SUSANTI 18/12/2019 18/12/2019 25/12/2019 65.71 0

20 338 0177A01012190000381 0177r0081219v000926 648711382 PONIJAN 18/12/2019 18/12/2019 25/12/2019 2.208 0

21 339 0177A01012190000382 0177r0081219v000959 94804053 MURTINAH 18/12/2019 18/12/2019 25/12/2019 46.899 0

No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

1 340 0177A01012190000383 0177r0081219v001005 2761217831 DJINEM 20/12/2019 19/12/2019 26/12/2019 39.272 0

PARJIYANTO .
2 341 0177A01012190000384 0177r0081219v001056 2462725181 MARSUDI HADI. 20/12/2019 19/12/2019 26/12/2019 321.621 0
S

3 342 0177A01012190000385 0177r0081219v001054 647923195 SUWITO REJO 20/12/2019 19/12/2019 26/12/2019 2.208 0

4 343 0177A01012190000386 0177r0081219v001055 648027281 KISMARTAYA 20/12/2019 19/12/2019 26/12/2019 599.053 0

5 344 0177A01012190000387 0177r0081219v001043 655950969 MULYADI 20/12/2019 19/12/2019 26/12/2019 211.568 0

6 345 0177A01012190000388 0177r0081219v001048 646923071 PAINAH 20/12/2019 19/12/2019 26/12/2019 14.132 0

7 346 0177A01012190000389 0177r0081219v001041 1034319071 WARIJEM 20/12/2019 19/12/2019 26/12/2019 478.133 0

8 347 0177A01012190000390 0177r0081219v001062 1160945728 SUHARYANI 20/12/2019 19/12/2019 26/12/2019 10.716 0

9 348 0177A01012190000391 0177r0081219v001065 1034134119 SRIYATINI 20/12/2019 19/12/2019 26/12/2019 44.956 0

10 349 0177A01012190000392 0177r0081219v001063 96658244 NING RUSWATI 20/12/2019 19/12/2019 26/12/2019 62.795 0

11 350 0177A01012190000393 0177r0081219v001053 2376520244 IRIANI 20/12/2019 19/12/2019 26/12/2019 52.433 0

12 351 0177A01012190000394 0177r0081219v001059 1034132433 PONIRAH 20/12/2019 19/12/2019 26/12/2019 74.867 0

13 352 0177A01012190000395 0177r0081219v001061 2165841044 KATINEM 20/12/2019 19/12/2019 26/12/2019 18.253 0

SITI ZAHROH,
14 353 0177A01012190000396 0177r0081219v001058 95106532 20/12/2019 19/12/2019 26/12/2019 34.004 0
B.A.
15 354 0177A01012190000397 0177r0081219v001064 1824433547 SRI YATI 20/12/2019 19/12/2019 26/12/2019 78.163 0

16 355 0177A01012190000398 0177r0081219v001007 649351181 SRI SUWARTI 20/12/2019 19/12/2019 26/12/2019 35.005 0

17 356 0177A01012190000399 0177r0081219v001027 1034131465 WIDODO 20/12/2019 19/12/2019 26/12/2019 279.639 0

18 357 0177A01012190000400 0177r0081219v001040 1034143334 KASMINAH 20/12/2019 19/12/2019 26/12/2019 41.541 0

19 358 0177A01012190000401 0177r0081219v001069 1034465927 SUNARDI 20/12/2019 19/12/2019 26/12/2019 590.044 0

20 359 0177A01012190000402 0177r0081219v001052 2177494929 REJO UTOMO 20/12/2019 19/12/2019 26/12/2019 7.625 0

B. WIJOTO
21 360 0177A01012190000403 0177r0081219v001011 648996467 PAWIRO / 20/12/2019 19/12/2019 26/12/2019 7.625 0
HALILAH
NAFHIAZKA AL
22 361 0177A01012190000404 0177r0081219v001033 1694246409 20/12/2019 19/12/2019 26/12/2019 20.21 0
KHALIS

23 362 0177A01012190000405 0177r0081219v001016 647926672 SUJINEM 20/12/2019 19/12/2019 26/12/2019 185.706 0

24 363 0177A01012190000406 0177r0081219v000999 94696334 BONIRAH 20/12/2019 19/12/2019 26/12/2019 32.443 0

LAILATUL
25 364 0177A01012190000407 0177r0081219v001024 649336263 20/12/2019 19/12/2019 26/12/2019 53.551 0
KHORIYAH

26 365 0177A01012190000408 0177r0081219v001017 94962789 RIYANTINAH 20/12/2019 19/12/2019 26/12/2019 58.144 0

27 366 0177A01012190000409 0177r0081219v001023 648494109 SUMILAH 20/12/2019 19/12/2019 26/12/2019 89.822 0

NITA CAHAYA
28 367 0177A01012190000410 0177r0081219v001000 1996179772 20/12/2019 19/12/2019 26/12/2019 116.065 0
SARI

29 368 0177A01012190000411 0177r0081219v001001 1034138902 M. NOOR HADI 20/12/2019 19/12/2019 26/12/2019 125.736 0
30 369 0177A01012190000412 0177r0081219v001019 1034097153 SURATINI 20/12/2019 19/12/2019 26/12/2019 52.433 0

31 370 0177A01012190000413 0177r0081219v001020 95045837 MARGONO 20/12/2019 19/12/2019 26/12/2019 128.079 0

WIDI HARJONO
32 371 0177A01012190000414 0177r0081219v001021 1830857049 20/12/2019 19/12/2019 26/12/2019 453.463 0
A RUWADI
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep Tgl. Plynn rsp By Tagihan By Verif

HAIKAL OKTA
1 527 0177A01001200000586 0177r0080120v001479 648400004 29/01/2020 27/01/2020 3/2/2020 367.647 0
FITRIAN

2 528 0177A01001200000587 0177r0080120v001504 2350536118 TIKA AMELIA 29/01/2020 27/01/2020 3/2/2020 20.21 0

3 529 0177A01001200000588 0177r0080120v001472 647462867 KHOIRIYAH 29/01/2020 27/01/2020 3/2/2020 154.376 0

4 530 0177A01001200000589 0177r0080120v001540 2219691148 ISBANDIYAH 29/01/2020 27/01/2020 3/2/2020 770.343 0

5 531 0177A01001200000590 0177r0080120v001478 94872824 MURJATI 29/01/2020 27/01/2020 3/2/2020 530.624 0

6 532 0177A01001200000591 0177r0080120v001539 2469075862 SUPIYEM 29/01/2020 27/01/2020 3/2/2020 15.353 0

7 533 0177A01001200000592 0177r0080120v001537 648802642 WALDINI 29/01/2020 27/01/2020 3/2/2020 160.861 0

8 534 0177A01001200000593 0177r0080120v001525 647746997 SUMIRAH 29/01/2020 27/01/2020 3/2/2020 38.862 0

9 535 0177A01001200000594 0177r0080120v001528 647764031 MARTINI 29/01/2020 27/01/2020 3/2/2020 312.612 0

10 536 0177A01001200000595 0177r0080120v001546 95148472 PAIJAH 29/01/2020 27/01/2020 3/2/2020 94.091 0

11 537 0177A01001200000596 0177r0080120v001517 94937725 SUROBO 29/01/2020 27/01/2020 3/2/2020 107.722 0

SELO
12 538 0177A01001200000597 0177r0080120v001548 647143356 SUGIATMOJO / 29/01/2020 27/01/2020 3/2/2020 397.323 0
SELO WIJOYO

FLORENTINA
13 539 0177A01001200000598 0177r0080120v001542 95385014 29/01/2020 27/01/2020 3/2/2020 656.085 0
SUKARTI
14 540 0177A01001200000599 0177r0080120v001531 1695084884 SARJIYEM 29/01/2020 27/01/2020 3/2/2020 81.873 0

15 541 0177A01001200000600 0177r0080120v001519 647412478 MUGIYONO 29/01/2020 27/01/2020 3/2/2020 719.765 0

MITRO
16 542 0177A01001200000601 0177r0080120v001473 1034157633 WIHARJO / 29/01/2020 27/01/2020 3/2/2020 45.868 0
SUGIYONO

17 543 0177A01001200000602 0177r0080120v001526 2215248963 YANTI 29/01/2020 27/01/2020 3/2/2020 337.666 0

SUHARDI
18 544 0177A01001200000603 0177r0080120v001512 648816208 HARDI 29/01/2020 27/01/2020 3/2/2020 101.45 0
WARSITO

19 545 0177A01001200000604 0177r0080120v001474 1034157126 SARING 29/01/2020 27/01/2020 3/2/2020 38.096 0

CHRISTIANA
20 546 0177A01001200000605 0177r0080120v001483 95001232 PARDJILAH, 29/01/2020 27/01/2020 3/2/2020 34.474 0
B.A.

21 547 0177A01001200000606 0177r0080120v001475 649062303 SARYATMAN 29/01/2020 27/01/2020 3/2/2020 35.387 0

22 548 0177A01001200000607 0177r0080120v001530 1034337982 HERI BUDIARSO 29/01/2020 27/01/2020 3/2/2020 15.103 0

23 549 0177A01001200000608 0177r0080120v001493 95108938 ISNI DIARTI 29/01/2020 27/01/2020 3/2/2020 19.253 0

BAMBANG
24 550 0177A01001200000609 0177r0080120v001494 95108927 29/01/2020 27/01/2020 3/2/2020 22.154 0
SUHARYANTO

25 551 0177A01001200000610 0177r0080120v001520 1034136461 DARTI 29/01/2020 27/01/2020 3/2/2020 37.36

26 552 0177A01001200000611 0177r0080120v001476 95019759 SABINAH 29/01/2020 27/01/2020 3/2/2020 34.004 0

SALUD
27 553 0177A01001200000612 0177r0080120v001477 207435868 29/01/2020 27/01/2020 3/2/2020 13.778 0
SUDARSO
28 554 0177A01001200000613 0177r0080120v001511 94812928 WARDIYEM 29/01/2020 27/01/2020 3/2/2020 2.208 0

29 555 0177A01001200000614 0177r0080120v001495 94713175 SUDARNO 29/01/2020 27/01/2020 3/2/2020 699.098 0

30 556 0177A01001200000615 0177r0080120v001510 647320713 MARDI UTOMO 29/01/2020 27/01/2020 3/2/2020 71.686 0

31 557 0177A01001200000616 0177r0080120v001516 2248544722 SRI WAHYUNI 29/01/2020 27/01/2020 3/2/2020 424.081 0

32 558 0177A01001200000617 0177r0080120v001551 94679166 RUPINGAH 29/01/2020 27/01/2020 3/2/2020 149.114

 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan
rsp Verif
NY. PERWITO
1 642 0177A01003200000001 0177r0080220v002004 647100641 UTOMO 1/3/2020 28/02/2020 6/3/2020 18.901 0
WAGINAH

2 643 0177A01003200000002 0177r0080220v002002 94572404 KEMAN 1/3/2020 28/02/2020 6/3/2020 49.665 0

3 644 0177A01003200000003 0177r0080220v002006 1316222818 TUGINAH 1/3/2020 28/02/2020 6/3/2020 3.444 0

SALUD
4 645 0177A01003200000004 0177r0080220v001965 207435868 1/3/2020 28/02/2020 6/3/2020 13.778 0
SUDARSO
SLAMET
5 646 0177A01003200000005 0177r0080220v002005 1316221751 1/3/2020 28/02/2020 6/3/2020 9.45 0
WIDODO

6 647 0177A01003200000006 0177r0080220v002014 2167618961 SUTARMI 1/3/2020 28/02/2020 6/3/2020 2.208 0

MARDI
7 648 0177A01003200000007 0177r0080220v002008 94986472 SISWOYO / 1/3/2020 28/02/2020 6/3/2020 20.755 0
SUMARDI
DUTY
8 649 0177A01003200000008 0177r0080220v001984 205913079 1/3/2020 28/02/2020 6/3/2020 47.486 0
FORTUNA, BA

9 650 0177A01003200000009 0177r0080220v001992 94802872 NGALIYEM 1/3/2020 28/02/2020 6/3/2020 37.919 0

 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan
rsp Verif

1 651 0177A01003200000010 0177r0080220v002042 1034140588 PURWANTI 1/3/2020 29/02/2020 7/3/2020 16.045 0

2 652 0177A01003200000011 0177r0080220v002041 1034137473 SATINI 1/3/2020 29/02/2020 7/3/2020 35.681 0

3 653 0177A01003200000012 0177r0080220v002065 1125733645 FAJARI 1/3/2020 29/02/2020 7/3/2020 37.212 0

4 654 0177A01003200000013 0177r0080220v002067 646822978 ROHGIMANTO 1/3/2020 29/02/2020 7/3/2020 125.18 0

5 655 0177A01003200000014 0177r0080220v002064 95491214 SUKADAR 1/3/2020 29/02/2020 7/3/2020 600.702 0

6 656 0177A01003200000015 0177r0080220v002066 94716674 WAGIMIN 1/3/2020 29/02/2020 7/3/2020 719.765 0

ARJO SUMARTO /
7 657 0177A01003200000016 0177r0080220v002071 648534058 1/3/2020 29/02/2020 7/3/2020 178.979 0
TUKIJO

8 658 0177A01003200000017 0177r0080220v002059 648747663 SODIRAH 1/3/2020 29/02/2020 7/3/2020 118.98 0

9 659 0177A01003200000018 0177r0080220v002045 1034161841 MARYONO 1/3/2020 29/02/2020 7/3/2020 2.915 0

10 660 0177A01003200000019 0177r0080220v002069 647745996 MURYATI 1/3/2020 29/02/2020 7/3/2020 33.768 0

11 661 0177A01003200000020 0177r0080220v002044 205661744 SADJIMIN 1/3/2020 29/02/2020 7/3/2020 30.382 0

NGATIJO /
12 662 0177A01003200000021 0177r0080220v002039 647531785 1/3/2020 29/02/2020 7/3/2020 108.941 0
TRISNO WIYONO

13 663 0177A01003200000022 0177r0080220v002060 114521128 NGADINEM 1/3/2020 29/02/2020 7/3/2020 175.031 0

14 664 0177A01003200000023 0177r0080220v002043 647918976 MARIYEM 1/3/2020 29/02/2020 7/3/2020 151.704 0

PANgInTEN
15 665 0177A01003200000024 0177r0080220v002068 647728964 PRAPTO 1/3/2020 29/02/2020 7/3/2020 106.026 0
SUDARmO

16 666 0177A01003200000025 0177r0080220v002040 650221975 ROKHIMIN 1/3/2020 29/02/2020 7/3/2020 50.344 0

17 667 0177A01003200000026 0177r0080220v002050 1916245416 IBNU SHOOIM 1/3/2020 29/02/2020 7/3/2020 20.21 0
 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan
rsp Verif
SELO
1 480 0177A01012190000522 0177r0081219v001458 647143356 SUGIATMOJO / 28/12/2019 26/12/2019 2/1/2020 397.323 0
SELO WIJOYO
Y.A.
2 481 0177A01012190000523 0177r0081219v001419 94990713 28/12/2019 26/12/2019 2/1/2020 0 0
SUPRANTONO

3 482 0177A01012190000524 0177r0081219v001367 647462867 KHOIRIYAH 28/12/2019 26/12/2019 2/1/2020 154.376 0

4 483 0177A01012190000525 0177r0081219v001424 2215248963 YANTI 28/12/2019 26/12/2019 2/1/2020 337.666 0

SALUD
5 484 0177A01012190000526 0177r0081219v001370 207435868 28/12/2019 26/12/2019 2/1/2020 13.778 0
SUDARSO

6 485 0177A01012190000527 0177r0081219v001449 95129436 WINDI YARTI 28/12/2019 26/12/2019 2/1/2020 34.004 0

7 486 0177A01012190000528 0177r0081219v001430 94794851 SUBARJO 28/12/2019 26/12/2019 2/1/2020 105.278 0

8 487 0177A01012190000529 0177r0081219v001432 646569494 JUMINEM 28/12/2019 26/12/2019 2/1/2020 61.559 0

BAMBANG
9 488 0177A01012190000530 0177r0081219v001369 95108927 28/12/2019 26/12/2019 2/1/2020 22.154 0
SUHARYANTO

10 489 0177A01012190000531 0177r0081219v001368 95108938 ISNI DIARTI 28/12/2019 26/12/2019 2/1/2020 19.253 0

11 490 0177A01012190000532 0177r0081219v001413 1034345158 SUKIMAH 28/12/2019 26/12/2019 2/1/2020 48.459 0

12 491 0177A01012190000533 0177r0081219v001443 2248544722 SRI WAHYUNI 28/12/2019 26/12/2019 2/1/2020 424.081 0

13 492 0177A01012190000534 0177r0081219v001436 648882167 RUKILAH 28/12/2019 26/12/2019 2/1/2020 23.464 0

14 493 0177A01012190000535 0177r0081219v001392 94795795 SUMARJILAH 28/12/2019 26/12/2019 2/1/2020 450.224

15 494 0177A01012190000536 0177r0081219v001402 94713175 SUDARNO 28/12/2019 26/12/2019 2/1/2020 699.098 0

16 495 0177A01012190000537 0177r0081219v001364 1696772182 BEJO SUSANTO 28/12/2019 26/12/2019 2/1/2020 23.758 0

SUPRAPTO
17 496 0177A01012190000538 0177r0081219v001451 94789901 ATMOJO, 28/12/2019 26/12/2019 2/1/2020 279.639 0
SLAMET

18 497 0177A01012190000539 0177r0081219v001365 2469075862 SUPIYEM 28/12/2019 26/12/2019 2/1/2020 18.591

TUKIYO AL.
19 498 0177A01012190000540 0177r0081219v001450 1696607706 28/12/2019 26/12/2019 2/1/2020 21.963 0
HADI PURNOMO

20 499 0177A01012190000541 0177r0081219v001414 95019759 SABINAH 28/12/2019 26/12/2019 2/1/2020 45.662 0

YACOBUS
21 500 0177A01012190000542 0177r0081219v001406 95144027 28/12/2019 26/12/2019 2/1/2020 786.094 0
HARSONO, S.PD.

22 501 0177A01012190000543 0177r0081219v001429 94812928 WARDIYEM 28/12/2019 26/12/2019 2/1/2020 32.973 0

CHRISTIANA
23 502 0177A01012190000544 0177r0081219v001387 95001232 28/12/2019 26/12/2019 2/1/2020 37.536 0
PARDJILAH, B.A.

MITRO WIHARJO
24 503 0177A01012190000545 0177r0081219v001363 1034157633 28/12/2019 26/12/2019 2/1/2020 45.868 0
/ SUGIYONO

25 504 0177A01012190000546 0177r0081219v001445 648802642 WALDINI 28/12/2019 26/12/2019 2/1/2020 160.861 0

26 505 0177A01012190000547 0177r0081219v001441 2647093015 PARJILAH 28/12/2019 26/12/2019 2/1/2020 1.033.938 0

27 506 0177A01012190000548 0177r0081219v001362 649285762 RONDIYAH 28/12/2019 26/12/2019 2/1/2020 871.891 0

28 507 0177A01012190000549 0177r0081219v001456 2219691148 ISBANDIYAH 28/12/2019 26/12/2019 2/1/2020 630.524 0

29 508 0177A01012190000550 0177r0081219v001448 1695084884 SARJIYEM 28/12/2019 26/12/2019 2/1/2020 81.873 0

SUHARDI HARDI
30 509 0177A01012190000551 0177r0081219v001453 648816208 28/12/2019 26/12/2019 2/1/2020 84.11 0
WARSITO

31 510 0177A01012190000552 0177r0081219v001454 648930611 SUMIYATI 28/12/2019 26/12/2019 2/1/2020 2.208 0

32 511 0177A01012190000553 0177r0081219v001461 1034337982 HERI BUDIARSO 28/12/2019 26/12/2019 2/1/2020 15.103 0

33 512 0177A01012190000554 0177r0081219v001460 647320713 MARDI UTOMO 28/12/2019 26/12/2019 2/1/2020 74.306 0

34 513 0177A01012190000555 0177r0081219v001428 648387369 TUKINEM 28/12/2019 26/12/2019 2/1/2020 437.712 0

35 514 0177A01012190000556 0177r0081219v001438 94937725 SUROBO 28/12/2019 26/12/2019 2/1/2020 213.499 0

36 515 0177A01012190000557 0177r0081219v001366 647764031 MARTINI 28/12/2019 26/12/2019 2/1/2020 312.612 0

37 516 0177A01012190000558 0177r0081219v001371 649062303 SARYATMAN 28/12/2019 26/12/2019 2/1/2020 38.449 0

38 517 0177A01012190000559 0177r0081219v001457 647746997 SUMIRAH 28/12/2019 26/12/2019 2/1/2020 35.623 0

39 518 0177A01012190000560 0177r0081219v001437 94872824 MURJATI 28/12/2019 26/12/2019 2/1/2020 536.748 0

40 519 0177A01012190000561 0177r0081219v001459 94700351 KAMIRAH 28/12/2019 26/12/2019 2/1/2020 62.766 0

41 520 0177A01012190000562 0177r0081219v001347 1034140588 PURWANTI 28/12/2019 26/12/2019 2/1/2020 17.664 0

42 521 0177A01012190000563 0177r0081219v001382 1034140847 HARTIYAH 28/12/2019 26/12/2019 2/1/2020 0 0

43 522 0177A01012190000564 0177r0081219v001380 94716674 WAGIMIN 28/12/2019 26/12/2019 2/1/2020 730.51 0

SUDIYANA,
44 523 0177A01012190000565 0177r0081219v001348 94659568 28/12/2019 26/12/2019 2/1/2020 46.457 0
BCTT

45 524 0177A01012190000566 0177r0081219v001373 650221975 ROKHIMIN 28/12/2019 26/12/2019 2/1/2020 52.684 0

46 525 0177A01012190000567 0177r0081219v001346 1034360583 MARYANTO 28/12/2019 26/12/2019 2/1/2020 653.877 0

47 526 0177A01012190000568 0177r0081219v001345 158068304 KASILAN 28/12/2019 26/12/2019 2/1/2020 191.433 0

48 527 0177A01012190000569 0177r0081219v001376 114521128 NGADINEM 28/12/2019 26/12/2019 2/1/2020 175.031 0

49 528 0177A01012190000570 0177r0081219v001379 1125733645 FAJARI 28/12/2019 26/12/2019 2/1/2020 37.212 0

PANgInTEN
50 529 0177A01012190000571 0177r0081219v001383 647728964 PRAPTO 28/12/2019 26/12/2019 2/1/2020 171.766 0
SUDARmO

51 530 0177A01012190000572 0177r0081219v001375 647918976 MARIYEM 28/12/2019 26/12/2019 2/1/2020 136.645 0

ARJO SUMARTO /
52 531 0177A01012190000573 0177r0081219v001384 648534058 28/12/2019 26/12/2019 2/1/2020 178.935 0
TUKIJO

53 532 0177A01012190000574 0177r0081219v001374 647745996 MURYATI 28/12/2019 26/12/2019 2/1/2020 6.006 0

HAIKAL OKTA
54 533 0177A01012190000575 0177r0081219v001385 648400004 28/12/2019 26/12/2019 2/1/2020 274.852 0
FITRIAN
 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan
rsp Verif

1 534 0177A01012190000576 0177r0081219v001509 650425869 SUYANTO 28/12/2019 27/12/2019 3/1/2020 20.225 0

DWIJO
2 535 0177A01012190000577 0177r0081219v001472 647276128 SUPRIHATIN / 28/12/2019 27/12/2019 3/1/2020 3.827 0
PRIHATIN

3 536 0177A01012190000578 0177r0081219v001507 94087214 SUMARYANTA 28/12/2019 27/12/2019 3/1/2020 17.075 0

DARYANTO /
4 537 0177A01012190000579 0177r0081219v001510 649503551 MADIYO HADI 28/12/2019 27/12/2019 3/1/2020 16.045 0
SUDARMINTO

5 538 0177A01012190000580 0177r0081219v001479 1699593761 WARTINI 28/12/2019 27/12/2019 3/1/2020 10.922 0

DUTY FORTUNA,
6 539 0177A01012190000581 0177r0081219v001492 205913079 28/12/2019 27/12/2019 3/1/2020 16.192 0
BA

7 540 0177A01012190000582 0177r0081219v001548 648608488 DARIYEM 28/12/2019 27/12/2019 3/1/2020 31.324 0

MARDI SISWOYO
8 541 0177A01012190000583 0177r0081219v001544 94986472 28/12/2019 27/12/2019 3/1/2020 20.755 0
/ SUMARDI

9 542 0177A01012190000584 0177r0081219v001471 94928613 KASILAH 28/12/2019 27/12/2019 3/1/2020 52.374 0

GIYONO / SUDI
10 543 0177A01012190000585 0177r0081219v001561 647200596 28/12/2019 27/12/2019 3/1/2020 30.765 0
WIYONO

11 544 0177A01012190000586 0177r0081219v001470 648158499 PARTINI 28/12/2019 27/12/2019 3/1/2020 227.454 0

CAHYA
12 545 0177A01012190000587 0177r0081219v001547 1370323877 28/12/2019 27/12/2019 3/1/2020 464.207 0
HERLAMBANG

13 546 0177A01012190000588 0177r0081219v001551 1034600591 SUPARTI 28/12/2019 27/12/2019 3/1/2020 21.344 0

14 547 0177A01012190000589 0177r0081219v001550 94930255 SUGINEM 28/12/2019 27/12/2019 3/1/2020 17.958 0

15 548 0177A01012190000590 0177r0081219v001555 1034142737 RAJILAH 28/12/2019 27/12/2019 3/1/2020 134.318 0

16 549 0177A01012190000591 0177r0081219v001545 94577973 SUBAGYA 28/12/2019 27/12/2019 3/1/2020 5.329 0

17 550 0177A01012190000592 0177r0081219v001469 2082473943 TRI HANTOKO 28/12/2019 27/12/2019 3/1/2020 2.208 0

18 551 0177A01012190000593 0177r0081219v001519 2076887676 SRI RUSMAWATI 28/12/2019 27/12/2019 3/1/2020 312.612 0

19 552 0177A01012190000594 0177r0081219v001533 1996141443 PARJIYEM 28/12/2019 27/12/2019 3/1/2020 2.414 0

20 553 0177A01012190000595 0177r0081219v001546 649608715 NGADIMAN 28/12/2019 27/12/2019 3/1/2020 363.157 0

21 554 0177A01012190000596 0177r0081219v001487 95179533 SUHARTI 28/12/2019 27/12/2019 3/1/2020 108.999 0

22 555 0177A01012190000597 0177r0081219v001540 647812001 SITI MUINAH 28/12/2019 27/12/2019 3/1/2020 2.208 0

23 556 0177A01012190000598 0177r0081219v001520 2167618961 SUTARMI 28/12/2019 27/12/2019 3/1/2020 2.208 0

24 557 0177A01012190000599 0177r0081219v001543 650437773 JUMILAH 28/12/2019 27/12/2019 3/1/2020 60.735 0

25 558 0177A01012190000600 0177r0081219v001537 1034348231 NGADIMIN 28/12/2019 27/12/2019 3/1/2020 20.078 0

26 559 0177A01012190000601 0177r0081219v001558 1034336125 WAGIYEM 28/12/2019 27/12/2019 3/1/2020 45.073 0

27 560 0177A01012190000602 0177r0081219v001553 94679166 RUPINGAH 28/12/2019 27/12/2019 3/1/2020 149.114

28 561 0177A01012190000603 0177r0081219v001559 94630858 JASIMAH 28/12/2019 27/12/2019 3/1/2020 107.985 0

29 562 0177A01012190000604 0177r0081219v001467 646746715 WAKIJO 28/12/2019 27/12/2019 3/1/2020 701.306 0

30 563 0177A01012190000605 0177r0081219v001529 1093324781 SUWARDI 28/12/2019 27/12/2019 3/1/2020 55.289 0

SRI
31 564 0177A01012190000606 0177r0081219v001541 95060698 28/12/2019 27/12/2019 3/1/2020 33.297 0
ROCHDJATINI

32 565 0177A01012190000607 0177r0081219v001532 2221951263 MARDINEM 28/12/2019 27/12/2019 3/1/2020 583.56 0

33 566 0177A01012190000608 0177r0081219v001525 94696413 PURWOKO 28/12/2019 27/12/2019 3/1/2020 27.968 0

34 567 0177A01012190000609 0177r0081219v001527 647412478 MUGIYONO 28/12/2019 27/12/2019 3/1/2020 719.765 0

NY. PERWITO
35 568 0177A01012190000610 0177r0081219v001528 647100641 UTOMO 28/12/2019 27/12/2019 3/1/2020 18.901 0
WAGINAH

36 569 0177A01012190000611 0177r0081219v001466 1034321837 SUBANDI 28/12/2019 27/12/2019 3/1/2020 2.915 0

37 570 0177A01012190000612 0177r0081219v001465 1262243507 SRI AYEM 28/12/2019 27/12/2019 3/1/2020 1.031.886 0

38 571 0177A01012190000613 0177r0081219v001526 95439655 SUBARDI 28/12/2019 27/12/2019 3/1/2020 816.859 0

39 572 0177A01012190000614 0177r0081219v001552 1034600589 SIS SUKAMTO 28/12/2019 27/12/2019 3/1/2020 189.534 0

AQILA NUR
40 573 0177A01012190000615 0177r0081219v001653 2573481936 29/12/2019 27/12/2019 3/1/2020 20.21 0
AYESHA
 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan
rsp Verif

1 574 0177A01012190000617 0177r0081219v001602 646609511 TUGI 30/12/2019 28/12/2019 4/1/2020 347.411 0

H. ZISAM
2 575 0177A01012190000618 0177r0081219v001600 94909015 30/12/2019 28/12/2019 4/1/2020 307.107 0
DAMIRI

3 576 0177A01012190000619 0177r0081219v001569 95028794 BADRI 30/12/2019 28/12/2019 4/1/2020 286.763 0

4 577 0177A01012190000620 0177r0081219v001575 648744827 NGATILAH 30/12/2019 28/12/2019 4/1/2020 30.294 0

5 578 0177A01012190000621 0177r0081219v001606 647632708 SUMINEM 30/12/2019 28/12/2019 4/1/2020 33.857 0

6 579 0177A01012190000622 0177r0081219v001598 2456380506 SURIP 30/12/2019 28/12/2019 4/1/2020 33.385 0

7 580 0177A01012190000623 0177r0081219v001605 96848998 SUPARMI , NY . 30/12/2019 28/12/2019 4/1/2020 41.423 0

8 581 0177A01012190000624 0177r0081219v001573 1034137473 SATINI 30/12/2019 28/12/2019 4/1/2020 32.591 0

9 582 0177A01012190000625 0177r0081219v001599 648294186 SOARJO . GIYO 30/12/2019 28/12/2019 4/1/2020 2.208 0

10 583 0177A01012190000626 0177r0081219v001594 646822978 ROHGIMANTO 30/12/2019 28/12/2019 4/1/2020 41.423 0

11 584 0177A01012190000627 0177r0081219v001596 652116576 PAILAH 30/12/2019 28/12/2019 4/1/2020 164.406 0

12 585 0177A01012190000628 0177r0081219v001601 651883285 SUGINAH 30/12/2019 28/12/2019 4/1/2020 26.967 0

13 586 0177A01012190000629 0177r0081219v001603 651499547 WATINAH 30/12/2019 28/12/2019 4/1/2020 21.55 0

TUMILAH HARJO
14 587 0177A01012190000630 0177r0081219v001607 1034344247 30/12/2019 28/12/2019 4/1/2020 123.278 0
PRANOTO, NY
15 588 0177A01012190000631 0177r0081219v001638 1526244221 NGATIJO 30/12/2019 28/12/2019 4/1/2020 17.752 0

TRI WASIYATI,
16 589 0177A01012190000632 0177r0081219v001611 97288187 30/12/2019 28/12/2019 4/1/2020 158.279 0
Dra.

17 590 0177A01012190000633 0177r0081219v001592 647458784 KARSINAH 30/12/2019 28/12/2019 4/1/2020 30.677 0

18 591 0177A01012190000634 0177r0081219v001578 1034161841 MARYONO 30/12/2019 28/12/2019 4/1/2020 2.915 0

CHRISTINA
19 592 0177A01012190000635 0177r0081219v001579 94736687 30/12/2019 28/12/2019 4/1/2020 9.009 0
SARJINAH

20 593 0177A01012190000636 0177r0081219v001608 94888473 WINARTO, B.A. 30/12/2019 28/12/2019 4/1/2020 3.062 0

WARNO
21 594 0177A01012190000637 0177r0081219v001620 648076858 DIHARJO / 30/12/2019 28/12/2019 4/1/2020 123.072 0
SADIMAN

22 595 0177A01012190000638 0177r0081219v001618 648578452 JUMALI 30/12/2019 28/12/2019 4/1/2020 42.776 0

23 596 0177A01012190000639 0177r0081219v001572 647918482 SIHTILAH 30/12/2019 28/12/2019 4/1/2020 18.96 0

24 597 0177A01012190000640 0177r0081219v001582 94682125 SITI ROJILAH 30/12/2019 28/12/2019 4/1/2020 180.065 0

25 598 0177A01012190000641 0177r0081219v001622 650849556 GIYEM 30/12/2019 28/12/2019 4/1/2020 20.873 0

TRI RAHARJO /
26 599 0177A01012190000642 0177r0081219v001628 647778262 30/12/2019 28/12/2019 4/1/2020 104.819 0
PARJILAN

27 600 0177A01012190000643 0177r0081219v001565 94553627 SITI HUSAINAH 30/12/2019 28/12/2019 4/1/2020 815.239 0

MARTINA
28 601 0177A01012190000644 0177r0081219v001566 94769201 30/12/2019 28/12/2019 4/1/2020 42.571 0
JUMINEM

29 602 0177A01012190000645 0177r0081219v001564 648986343 MARYADI 30/12/2019 28/12/2019 4/1/2020 18.665 0

30 603 0177A01012190000646 0177r0081219v001567 1285344742 KASIYEM 30/12/2019 28/12/2019 4/1/2020 18.43 0

31 604 0177A01012190000647 0177r0081219v001610 1875473943 SUMARTINI 30/12/2019 28/12/2019 4/1/2020 339.697 0

32 605 0177A01012190000648 0177r0081219v001571 647379281 NGADINAH 30/12/2019 28/12/2019 4/1/2020 48.076 0

SAKIDJO
33 606 0177A01012190000649 0177r0081219v001640 1261674066 DARTOATMODJ 30/12/2019 28/12/2019 4/1/2020 101.597 0
O
MADIYO
34 607 0177A01012190000650 0177r0081219v001625 647386784 30/12/2019 28/12/2019 4/1/2020 135.025 0
DIHARJO

35 608 0177A01012190000651 0177r0081219v001616 165445784 PARJIYEM 30/12/2019 28/12/2019 4/1/2020 27.969 0

36 609 0177A01012190000652 0177r0081219v001632 647876542 NGADIRAH 30/12/2019 28/12/2019 4/1/2020 354.612 0

37 610 0177A01012190000653 0177r0081219v001609 96613108 TUHADI 30/12/2019 28/12/2019 4/1/2020 595.873 0

38 611 0177A01012190000654 0177r0081219v001617 648001451 WAGINAH 30/12/2019 28/12/2019 4/1/2020 286.902 0

39 612 0177A01012190000655 0177r0081219v001635 95491214 SUKADAR 30/12/2019 28/12/2019 4/1/2020 602.292 0

40 613 0177A01012190000656 0177r0081219v001577 1815939055 kasilah 30/12/2019 28/12/2019 4/1/2020 47.723 0

41 614 0177A01012190000657 0177r0081219v001641 2042098378 SITI BADRIYAH 30/12/2019 28/12/2019 4/1/2020 24.289 0

42 615 0177A01012190000658 0177r0081219v001637 646381484 TINI 30/12/2019 28/12/2019 4/1/2020 70.744 0

43 616 0177A01012190000659 0177r0081219v001623 1034136461 DARTI 30/12/2019 28/12/2019 4/1/2020 37.36 0

MOHAMMAD
44 617 0177A01012190000660 0177r0081219v001636 203479727 30/12/2019 28/12/2019 4/1/2020 16.222 0
HANIF, S.Th.I.
45 618 0177A01012190000661 0177r0081219v001639 648805937 ELVIRA FEBRIAN 30/12/2019 28/12/2019 4/1/2020 44.043 0

46 619 0177A01012190000662 0177r0081219v001643 2047100084 TRIYONO, Drs 30/12/2019 28/12/2019 4/1/2020 3.003 0

47 620 0177A01012190000663 0177r0081219v001644 97427812 SITI RONDIYAH 30/12/2019 28/12/2019 4/1/2020 884.239 0

MARYANTO /
48 621 0177A01012190000664 0177r0081219v001631 646998783 30/12/2019 28/12/2019 4/1/2020 18.253 0
PAIT

49 622 0177A01012190000665 0177r0081219v001645 649354511 TUMIDAH 30/12/2019 28/12/2019 4/1/2020 154.376 0

50 623 0177A01012190000666 0177r0081219v001587 648495573 DARYANTO 30/12/2019 28/12/2019 4/1/2020 5.123 0

51 624 0177A01012190000667 0177r0081219v001642 94928703 LILIK MULYOTO 30/12/2019 28/12/2019 4/1/2020 419.459 0

52 625 0177A01012190000668 0177r0081219v001574 94566723 EDDY SUSANTO 30/12/2019 28/12/2019 4/1/2020 699.098 0

MARTO
53 626 0177A01001200000001 0177r0081219v001820 647480564 1/1/2020 28/12/2019 4/1/2020 176.638 0
SENTONO
 Tgl. Plynn By
No. No. Rx No. Apotek No. SEP/Kunjungan No. Kartu Nama Tgl. Entry Tgl. Resep By Tagihan
rsp Verif

1 656 0177A01001200000031 0177r0081219v001824 94983502 SUGIJONO 2/1/2020 31/12/2019 7/1/2020 158.78 0

2 657 0177A01001200000032 0177r0081219v001795 1034286581 JUMIDAH 2/1/2020 31/12/2019 7/1/2020 159.809 0

3 658 0177A01001200000033 0177r0081219v001746 2466883192 MARSINI 2/1/2020 31/12/2019 7/1/2020 158.279 0

4 659 0177A01001200000034 0177r0081219v001760 648242324 MARIYAM 2/1/2020 31/12/2019 7/1/2020 173.824 0

5 660 0177A01001200000035 0177r0081219v001765 647888398 WADJIYEM 2/1/2020 31/12/2019 7/1/2020 35.211 0

6 661 0177A01001200000036 0177r0081219v001743 1695079776 NY RANTIYEM 2/1/2020 31/12/2019 7/1/2020 155.53 0

7 662 0177A01001200000037 0177r0081219v001762 94982095 MURDIYATI 2/1/2020 31/12/2019 7/1/2020 43.675 0

8 663 0177A01001200000038 0177r0081219v001750 649192601 WAGIYO 2/1/2020 31/12/2019 7/1/2020 32.398 0

MURNI / MURDI
9 664 0177A01001200000039 0177r0081219v001741 648989807 2/1/2020 31/12/2019 7/1/2020 44.514 0
WIYONO, NY

10 665 0177A01001200000040 0177r0081219v001751 1377121026 SUNARTI 2/1/2020 31/12/2019 7/1/2020 84.963 0

11 666 0177A01001200000041 0177r0081219v001754 648577978 PUJI SETITI 2/1/2020 31/12/2019 7/1/2020 86.848 0

12 667 0177A01001200000042 0177r0081219v001806 1096263044 SUBARDI 2/1/2020 31/12/2019 7/1/2020 36.859 0

13 668 0177A01001200000043 0177r0081219v001759 94997709 H.M. YAINUDIN 2/1/2020 31/12/2019 7/1/2020 595.962 0

14 669 0177A01001200000044 0177r0081219v001794 648106931 WINURJIKAH 2/1/2020 31/12/2019 7/1/2020 68.537 0

15 670 0177A01001200000045 0177r0081219v001758 649414574 SUYADI 2/1/2020 31/12/2019 7/1/2020 140.265 0

MUGI HARJO,
16 671 0177A01001200000046 0177r0081219v001802 648187784 2/1/2020 31/12/2019 7/1/2020 38.096 0
KASIL

17 672 0177A01001200000047 0177r0081219v001805 94690067 KARTINI 2/1/2020 31/12/2019 7/1/2020 33.973 0

18 673 0177A01001200000048 0177r0081219v001756 205661744 SADJIMIN 2/1/2020 31/12/2019 7/1/2020 11.953 0

19 674 0177A01001200000049 0177r0081219v001803 649414721 PARINEM 2/1/2020 31/12/2019 7/1/2020 804.877 0

ACHROM NUR
20 675 0177A01001200000050 0177r0081219v001796 84074422 2/1/2020 31/12/2019 7/1/2020 474.483 0
MIYATI

21 676 0177A01001200000051 0177r0081219v001808 97279345 Dra. HARJANTI 2/1/2020 31/12/2019 7/1/2020 596.05 0

YOJANA
22 677 0177A01001200000052 0177r0081219v001778 95095629 2/1/2020 31/12/2019 7/1/2020 25.583 0
HINDARTA

23 678 0177A01001200000053 0177r0081219v001809 646770183 NGATINEM 2/1/2020 31/12/2019 7/1/2020 41.099 0

24 679 0177A01001200000054 0177r0081219v001818 650872506 MULYADI 2/1/2020 31/12/2019 7/1/2020 14.132 0

25 680 0177A01001200000055 0177r0081219v001774 647242604 WASIYEM 2/1/2020 31/12/2019 7/1/2020 18.429 0

26 681 0177A01001200000056 0177r0081219v001819 96295533 PAMUJI 2/1/2020 31/12/2019 7/1/2020 471.892 0

27 682 0177A01001200000057 0177r0081219v001773 1034154696 SURANTI 2/1/2020 31/12/2019 7/1/2020 34.004 0

28 683 0177A01001200000058 0177r0081219v001800 95044544 SURATMINI 2/1/2020 31/12/2019 7/1/2020 726.36 0