SURAT PESANAN OBAT RSUD WARU

TAHUN ANGGARAN 2018

Mengajukan pemesanan obat mengandung Prekursor Farmasi kepada :

Nama industry farmasi/ PBF :
Alamat :
Telp. :

VOLUME SATUAN harga HARGA

NO NAMA OBAT PENYEDIA
satuan Pembelian Kemasan Pabrik bok/dus total/unit Non e-Catalog ONGKIR TOTAL
1 2 3 4 5 6 7 8 9 10 11
1 Amoxicillin 500mg Kap 100 5,000 dus, 10 blister @10 Tab 50 PT Bernofarm Rp 407.00 Rp 407.00 Rp - Rp 2,035,000.00
2 Asam Memenamat Tab 100 10,000 dus, 10 blister @10 Tab 100 PT Bernofarm Rp 140.00 Rp 140.00 Rp - Rp 1,400,000.00
3 Asam Traneksamat tab 100 1,500 dus, 10 blister @10 Tab 15 PT Bernofarm Rp 1,287.00 Rp 1,287.00 Rp - Rp 1,930,500.00
4 Cefadroxil Tab 100 2,500 dus, 10 blister @10 kap 25 PT Bernofarm Rp 666.00 Rp 666.00 Rp - Rp 1,665,000.00
5 Cefixim 200mg Tab 30 300 dus, 10 blister @10 kap 10 PT Bernofarm Rp 3,465.00 Rp 3,465.00 Rp - Rp 1,039,500.00
6 Ciprofloxacin Tab 100 2,500 dus, 10 blister @10 kap 25 PT Bernofarm Rp 385.00 Rp 385.00 Rp - Rp 962,500.00
7 Clorampenicol 250mg Tab 100 2,000 dus, 10 blister @10 kap 20 PT Bernofarm Rp 495.00 Rp 495.00 Rp - Rp 990,000.00
8 Dexametason injeksi 100 1,500 dus, 100ampul 15 PT Bernofarm Rp 1,567.00 Rp 1,567.00 Rp - Rp 2,350,500.00
9 Dexamethason Tab 100 2,000 dus, 10 blister @10 Tab 20 PT Bernofarm Rp 69.00 Rp 69.00 Rp - Rp 138,000.00
dus, 10 blister @10
10 Lansoprazol Tab 100 2,000 20 PT Bernofarm Rp 697.00 Rp 697.00 Rp - Rp 1,394,000.00
kapsul
dus, 1 vial
11 Omeprazol 40mg Injeksi 1 50 50 PT Bernofarm Rp 16,997.00 Rp 16,997.00 Rp - Rp 849,850.00
serbuk+pelarut
12 Simvastatin 10mg Tab 100 2,000 dus, 10 blister @10 kap 20 PT Bernofarm Rp 277.00 Rp 277.00 Rp - Rp 554,000.00
13 Simvastatin 20mg Tab 100 2,000 dus, 10 blister @10 kap 20 PT Bernofarm Rp 554.00 Rp 554.00 Rp - Rp 1,108,000.00
TOTAL PEMBAYARAN Rp 16,416,850.00

Pamekasan,
Apoteker RSUD WARU

Nur Fajariah, S.Farm., Apt.

SIPA : 19811011/SIPA-35.28/2017/2 05