Lplpo TW 3 2020

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSKESMAS TAHUN 2020

DOKUMEN NOMOR TANGGAL
DINKES
PUSKESMAS : SIMANGALAM LAPORAN TRIWULAN : I (II) III IV GFK 18/IFK/3/2020 30-Sep-20
KECAMATAN : KUALUH SELATAN PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
KABUPATEN : LABUHANBATU UTARA
PROVINSI : SUMATERA UTARA
JUMLAH PEMBERIAN
HARGA SATUAN STOK PENERI PERSEDI PEMAKA SISA STOK PERMIN
NO NAMA OBAT SATUAN
(Rp) AWAL MAAN AAN IAN STOK OPT TAAN
TOTAL
DAK APBDI APBD II TOTAL HARGA KET
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Bahan Obat-obatan (DAK )
Acetyl cysteine/ N-Asetil sistein tablet/kaplet/kapsul

1 capsule 357.00 580 580 580 - 2,000 - -
200 mg -
2 Acyclovir 200 mg Tablet 1,050.00 - - - - - -
3 Alopurinol tablet 100 mg tablet 97.00 3,340 - 3,340 3,214 - -
4 Alopurinol tablet 100 mg tablet 104.00 - - - - - -
5 Ambroxol 15 mg/5 ml botol 6,600.00 100 100 200 164 100 100 100 660,000
6 Ambroxol tab 30 mg tablet 330.00 2,000 500 2,500 2,248 2,000 2000 2,000 660,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 - - - - - -
8 Aminofilin tablet 200 mg tablet 92.00 - - - - - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 - - - - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 350 - 350 180 - 2,000 - -
Amlodipin/Amlodipine/Amlodipine Besylate/Amlodipine
11 tablet 78.00 600 1,200 1,120 3,000 3000 3,000 234,000
Besilate tablet/kapsul/kaplet 5 mg
600
Amlodipin/Amlodipine/Amlodipine Besilate
12 Kaplet 94.00 900 1,860 1,470 1,020 1020 1,020 95,880
tablet/kapsul/kaplet 10 mg 960
13 Amoksisilin 100 mg/mL botol 13,500.00 - 10 10 10 50 10 10 135,000
14 Amoksisilin 250 mg kapsul Kapsul 203.00 1,000 200 1,200 211 - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 20 50 70 61 50 - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 120 60 180 135 100 60 60 220,200
Amoksisilin/Amoxicillin tablet/kapsul/kaplet/kaptab
17 kaptab 261.00 - - - 5,000 5000 5,000 1,305,000
500 mg, kemasan strip/blister (G) -
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - - -
19 Antasida Tablet box 5,594.00 - - - - - -
20 Antasida Tablet tablet 200.00 3,415 - 3,415 1,597 1,943 3,000 - -
21 Antasida Tab Tablet 355.00 - 1,500 1,500 1,796 - -
Page 1
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Antasida tab kunyah, kombinasi: Aluminium Hidroksida
22 tablet 60.00 - - - 3,000 3000 3,000 180,000
200 mg + Magnesium Hidroksida 200 mg -
Antasida suspensi, kombinasi: Aluminium Hidroksida
23 botol 2,189.00 106 206 149 100 100 100 218,900
200 mg + Magnesium Hidroksida 200 mg 100
24 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g tube
+ Polimiksin 10.000
3,071.00
IU/g 39 64 9 47 50 50 50 153,550
25
Antifungi DOEN Salep, Kombinasi: Asam Benzoat 6% +
25 pot 4,540.00 54 78 4 59 48 48 48 217,920
Asam Salisilat 3% 24
Antihemoroid, Kombinasi sup: bismut subgalat supposit
26 3,325.00 20 20 25 - -
heksaklorofen oria -
27 Arkine 100 tablet 687.50 - - - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - - - - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 2,850 500 3,350 3,127 - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - 20 - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - - - - - -
33 Bedak salisil serbuk 2% dus 1,040.00 10 - 10 42 30 - -
34 Bedak Salisil Kotak 8,000.00 - 16 16 16 30 30 30 240,000
35 Betametason krim 0,5 mg/g tube 3,388.00 15 - 15 15 12 40 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 1 25 26 28 25 25 25 33,500
Biosat 1,5 Serum antitetanus (A.T.S) inj 1500 IU/amp
37 Ampul 130,999.00 - - - 1 - -
(i.m) -
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - - 1 - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - - - - -
selaput -
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 159 - 159 3 50 50 - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - 24 24 33 - -
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 560 - 560 50 190 - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - 1 - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - 1 - -
tablet
46 Cetirizin Hydrochloride salut 94.00 190 190 300 - - -
selaput -
47 Cetirizine tablet 10 mg tablet 101.00 1,500 - 1,500 400 2,000 1000 1,000 101,000
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 2 50 52 50 100 100 100 297,300
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - - -
Page 2
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
Chlorpromazine hydrochloride/ Chlorpromazine
50 salut 165.00 100 100 100 - -
/Klorpromazin tablet/kaplet salut selaput 100 mg
selaput -
Clindamycin hydrochloride/ Clindamycin/ Klindamisin
51 kapsul 770.00 - - - 1,000 1000 1,000 770,000
tablet/kapsul/kaplet 150 mg -
52 Codeine 10 mg tablet 600.00 - - - - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 50 30 80 45 30 - -
Cotrimoxazole/ Cotrimoksazole/ Kotrimoksazol (anak)
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 - - - 50 50 50 109,500
trimetoprim 40 mg (susp 240 mg) -
Cotrimoxazole/ Cotrimoksazole/ Kotrimoksazol (dewasa)
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 - - - - -
mg (tab/kaptab 480 mg) -
Cyanocobalamin/cyanocobalamine/sianokbalamin(Vit
56 tablet 47.00 - - - 1,500 - -
B12) tab/kaps/kapl/ 50 mg
-
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 655 655 605 - -
mg/ml -
58 Dexamethason inj Ampul 4,500.00 - - - - - -
59 Dexametason Tablet 0,5 mg Tablet 33.00 5,000 - 5,000 5,150 - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - - -
61 Dekstrofen Syrup Botol 11,550.00 15 - 15 3 - - -
62 Diazepam 2 mg Tablet 86.00 100 - 100 100 - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 20 - 20 20 - -
65 Diclofenac Sodium 25 mg Tablet 141.00 - - - - - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - 2,000 2,000 2,000 2,800 2800 2,800 380,800
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - - - - - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - - - 60 90 90
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - - -
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - - -
71 Digoksin 0,25 mg Tablet 104.00 - - - - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - - - - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 90 90 70 - -
Plastik -
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 50 - 50 120 - -
75 Domperidon tablet 10 mg tablet 86.00 - - - - 2,000 1500 1,500 129,000
Page 3
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 3 - 3 3 - -
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 3 - 3 3 - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - 3 - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 5 5 5 - -

-
kaptab
80 Eritromisin kapl 500 mg salut 765.00 - - - - -
selaput -
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 - - - - - -
83 Eugenol cairan botol 21,091.00 - - - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 100 - 100 100 - -
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 10 - 10 10 20 - -
Fitomenadion/Phytomenadion (Vit K) tablet/kaplet salut
87 tablet 747.00 980 980 500 380 - -
gula 10 mg -
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 - 100 100 99 100 - -
Fitomenadion / Phytomenadion (Vitamin k1) injeksi 2
89 ampul 3,867.00 - 30 30 - -
mg/ml 30
90 Fituno Tab tablet 4,163.10 - - - - - -
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - - - -
92 Furosemide tablet 40 mg tablet 77.00 200 - 200 200 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - 4 4 - -

4
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - 4 4 4 - -
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 3,400 3,900 3,480 1,000 1000 1,000 125,000
500
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 - - - - - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 4,000 4,000 3,900 - -

-
99 Griseofulvin tablet 125 mg tablet 232.00 - - - 70 - -
100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - - -
101 Haloperidol 0,5 mg Tablet 55.00 100 - 100 100 - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - - - -
103 Hidrokortison krim 2,5 % tube 2,640.00 33 24 57 11 57 50 48 48 126,720
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - - -
Page 4
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
105 Hustab Syrup botol 11,550.00 43 50 93 11 75 50 50 50 577,500
106 Hustab P Tablet 8 mg Tablet 256.67 - 1,200 1,200 1,200 2,000 2000 2,000 513,340
107 Hustab Tablet tablet 437.00 - - - - 3,000 3000 3,000 1,311,000
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - - -
selaput -
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 5,570 5,570 435 3,400
selaput -
110 Ibuprofen 200 mg Tablet 550.00 - - - 760 - -
111 Ibuprofen 400 mg Tablet 800.00 - - - - - -
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 11 50 61 55 30 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - - 50 50 50 138,800
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - - - - -

-
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 2,710 - 2,710 2,020 - -
Kalsium Laktat/ Calcium lactate (Kalk)
116 tablet 63.00 - - 340 - -
tablet/kapsul/kaplet 500 mg -
117 Kanamycin 1 gr inj vial 10,768.00 - - - - - -
118 Kaptopril 12,5 mg tablet 68.00 1,000 300 1,300 1,400 1,000 1000 1,000 68,000
119 Ketokenazol tablet 200 mg tablet 278.00 200 - 200 - - -
120 Ketokonazol tablet 200 mg tablet 297.00 - - - - - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 1,100 - 1,100 500 1,500 - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 700 200 900 1,398 600 600 600 396,000
123 Kloramfenikol Salep 2% tube 3,349.00 - - - 8 - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 - - - - - -
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - - - - - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - - - - -
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 5,819 - 5,819 444 4,964 3,000 - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - 1,000 - -
129 Klorfeniramin maleat tablet 25.00 - 1,000 1,000 1,000 4,000 4000 4,000 100,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 1,000 300 1,300 1,300 2,000 - -
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 1,500 - 1,500 780 2,000 300 300 385,125
132 Lidocaine Injeksi 2 % ampul 1,203.00 100 - 100 91 - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 700 200 900 900 1,000 700 700 182,000
134 Meloksikam 7,5 mg tablet 795.68 980 - 980 430 2,000 - -
Page 5
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
135 Meloxicam tab15 mg tablet 1,438.80 1,020 300 1,320 1,420 - -
136 Meloxicam 15 mg Tablet 980.00 - - - 240 - -
Metformin Hydrochloride/ Metformin tablet
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 100 100 100 1,000 - -
strip/blister (G) selaput -
Metilprednisolon/methylprednisolone tab/kaps/kapl 4
138 tablet 137.00 2,000 2,000 1,630 2,000 2000 2,000 274,000
mg -
139 Metilprednisolon tablet 4 mg tablet 146.00 - 200 200 270 - -
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 100 - 100 100 - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - - -
Metoclopramide hydrochloride
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 1,070 1,070 440 - -
mg -
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - - - 20 - -
146 Metronidazole tablet 500 mg tablet 264.00 100 - 100 200 185 2,000 700 700 184,800
147 MgSO4 20 % botol 13,500.00 6 - 6 6 - -
148 MgSO4 40 % botol 13,500.00 2 - 2 2 - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 54 24 78 24 48 60 24 24 86,040
150 NaCl 0,9 % 500 ml botol 6,840.00 - 20 20 20 20 - -
Natrium Diklofenak tablet/kapsul/kaplet salit enterik
151 tablet 132.00 - - 280 - -
25 mg -
152 tablet 127.00 500 500 1,060 - -
50 mg -
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 1,195 - 1,195 1,800 835 - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 400 - 400 200 500 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - 200 200 200 300 300 300 265,800
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 4 - 4 2 6 - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - - - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - - - -
161 Omeprazol Tab Tablet 650.00 - 200 200 620 3,000 200 200 130,000
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 5 - 5 - 10 - -
163 Paracetamol Tab 500 mg tablet 290.00 - - - - - -
Page 6
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
164 Paracetamol kaplet 500 mg kaplet 165.00 1,574 1,500 3,074 1,285 2,050 5,200 5200 5,200 858,000
Paracetamol/parasetamol drops 100 mg/ml btl @15 ml
165 bottle 6,981.00 - - - - -
(60 ml/0,6 ml) (G) -
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - 20 20 20 - -
167 Pehacain Injeksi ampul 3,113.06 143 - 143 120 - -
168 Pehacain Injeksi Ampul 3,113.05 3 100 103 103 100 100 100 311,305
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - - - -
170 Pehastan 500 mg tablet 445.50 20 - 20 - 1,000 1000 1,000 445,500
171 Pehavral tablet 935.00 500 500 1,000 820 800 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 17 - 17 4 - - -
173 Peridol Syrup 60 ml botol 19,800.00 12 - 12 - 60 - -
Perio Kin Spray Chlorhexidin Gluconat/ Klorheksidin
174 botol 124,355.00 - - - - -
0,2 % -
175 Phaproxin 500 mg tablet 880.00 100 - 100 100 - -
Pirantel pamoat / pyrantel pamoate tab/kaps/kapl 125
176 tablet 302.00 96 96 2 1,000 - -
mg -
177 Pirantel pamoat 125 mg tab tablet 322.00 - 200 200 210 - -
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 33 - 33 8 - -
179 Pirantel Pamoat syrup botol 10,778.00 - - - - - -
Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg
180 Tablet 124.00 3,828 3,828 941 3,540 - -
(HCl) -
181 tablet 129.00 3,000 3,500 3,150 3,000 2000 2,000 258,000
(HCl) 500
182 Prednison tablet 5 mg tablet 76.00 2,060 500 2,560 2,680 2,000 1000 1,000 76,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 4,400 - 4,400 1,700 - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 1,712 200 1,912 1,070 2,000 500 500 71,000
185 Pyridol Syrup 60 ml botol 18,150.00 48 5 53 35 39 100 - -
186 Ranitidin 150 mg Tablet tablet 660.00 2,900 500 3,400 2,381 3,000 1000 1,000 660,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 33 50 83 6 69 100 100 100 153,100
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 30 - 30 - - -
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - - - - -
191 Ringer Laktat 500 ml botol 7,630.00 - 20 20 20 20 - -
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - - - - - -
194 Salbutamol 2 mg tab tablet 67.00 - - - - - -
Page 7
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,700 - 1,700 1,360 - -
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 148 - 148 140 - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - - - - -
Salep 2-4, kombinasi: asam salisilat 2% + belerang
198 pot 2,654.00 50 74 29 50 48 48 127,392
endap 4% 24
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - - - - - -
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - - 10 10 10 49,980
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - - 50 - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 1,730 1,730 1,840 210 210 210 23,100
Selaput -
203 Simvastatin tablet 10 mg Tablet 117.00 - - - - - -
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 1,000 1,000 670 - -
selaput -
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - - - - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 - - - - - -
Tiamin (Vitamin B1) Tablet/Kapsul/kaplet 50 mg
208 tablet 84.00 150 150 - 1,000 700 700 58,800
(HCL/Nitrat) -
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - 200 200 200 - -
tablet
Trihexyphenidyl hydrochloride (HCl)/ Triheksifenidil
210 salut 93.00 100 100 100 - -
tablet/kapsul/kaplet 2 mg
selaput -
211 Vapril 25 mg tablet 193.00 - - - - - -
Ventolin Rotahaler (Alat Hirup Salbutamol 200
212 box 6,550.00 - - - - -
mcg/kapsul) -
213 Vitamin B Kompleks tablet 123.00 4,261 - 4,261 2,210 3,000 1500 1,500 184,500
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 - - - 50 - -
215 Vitamin B12 tablet 50 mcg tablet 52.00 4,900 2,000 6,900 6,785 2,500 2500 2,500 130,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 685 - 685 - - -
217 Vitamin B6 10 mg tablet 138.00 - - - - - -
Wida Bes Asetat Ringer (Asering) (Softbag, Flexy bag, Botol
218 9,646.00 - - - - -
plabot Plastik -
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 52 - 52 8 - -
OBAT GIZI (DAK 2019) - - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - 2,000 - -
Page 8
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
221 Hemafort tablet 834.90 2,100 2,000 4,100 3,170 7,200 7200 7,200 6,011,280
Mineral Mix (Bismuth subcitrat tripotassium, copper
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 40 40 40 - -
chloride, zinc acetate) -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - - -
Retnol Acetat/ Retinol (Vitamin A) Kaps Lunak 200.000
224 Kapsul 581.00 - - - - -
IU -
BAHAN MEDIS HABIS PAKAI (DAK ) - - - -
225 Allkohol 70% bottle 28,733.33 5 - 5 4 3 - -
226 Alkohol 70% 1L botol 28,750.00 - - - - 3 3 3 86,250
227 Arm sling L buah 17,424.00 - - - - - -
228 Arm sling M buah 17,424.00 - - - - - -
229 Arm sling S buah 17,424.00 - - - - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 21 - 21 11 10 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 - - - - - -
232 Aximed Syringe 1 cc Dus 103,750.00 20 - 20 - - -
233 Aximed Syringe 3 cc Dus 103,125.00 266 2 268 1 208 2 2 2 206,250
234 Blood Lancet box 16,022.60 - - - - - -
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - - - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - - - -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - - - - - -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - - - -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - - - - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 6 - 6 - - -
Page 9
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - - - - - -
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - - - -
255 Dermafix T 10x12cm pcs 6,939.90 - - - - - -
256 Examination Gloves size L box 58,564.00 - - - - - -
257 Examination Gloves size M box 58,564.00 2 2 4 3 3 3 3 175,692
258 Examination Gloves size S box 58,564.00 - - - - - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - 10 - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 - 5 5 5 - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - -
267 Hb Sahli set 96,800.00 - - - - - -
268 Hidrogen Peroxide 3% botol 3,864.00 - - - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - - -
270 Infuset pcs 6,166.16 - 20 20 40 - -
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 10 20 30 25 15 15 15 122,476
274 IV- Cath WP, with wings & port no 26 pcs 10,477.39 10 20 30 25 - -
275 Kapas pembalut 250 gr roll 13,733.33 6 - 6 6 - -
276 Kapas pembalut 250 gr roll 13,750.00 - 5 5 5 - -
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 5 5 5 30 - -
Page 10
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
278 Kasa kompres steril 40 x 40 pcs 1,760.00 104 - 104 180 - -
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - - - - - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - - - - -
282 Lysol 1 liter botol 47,150.00 3 - 3 3 5 - -
283 Masker Ear Loop Box 20,202.00 - - - - - -
284 Masker Tie on Box 19,869.00 6 - 6 - 30 - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - - - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - - -
289 Onemed Alcohol Swab botol 11,000.00 - - - - - -
290 Onemed Blood Lancet box 16,022.60 - - - - - -
291 Onesept 500 ml botol 30,360.00 10 - 10 5 - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 5 - 5 5 - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - - -
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - - - - - -
295 Safeglove Examination Gloves L box 39,182.00 - - - - - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - - - - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - - - -
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - - - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - - - -
300 Stera Infuset anak pcs 3,850.00 - - - - - -
301 Surgical Mask Earloop box 18,150.00 - - - - - -
302 Surgical Mask Tie On box 18,150.00 - 10 10 10 - -
303 Swab 2 ply dus 14,040.84 - - - - - -
304 Syringe 10 cc dus 167,266.70 - - - - - -
305 Syringe 1cc pcs 1,045.80 181 - 181 20 181 - -
306 Syringe 1cc dus 106,523.56 - - - - - -
307 Syringe 3cc dus 107,421.38 - - - - - -
Page 11
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
308 Syringe 5cc dus 119,090.61 9 - 9 - - -
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - - -
312 Tp. Disposable Syringe 5 cc pcs 892.78 200 - 200 200 - -

Tp. Infusion Set Pediatric 60 drops/ml with Y Type,
313 pcs 7,072.50 - - 20 - -
Airvent, Luer Lock -
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - - -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - - -
318 Urine bag steril (t-valve) pcs 3,300.00 - - - - - -
PEMERIKSAAN HIV - - - -
319 HIV Device Box 707,143.00 - 14 14 14 - -
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS - - - -
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - - - - - -
SUMBER DANA APBD I - - - -
VAKSIN - - - -
321 BCG +Pelarut BCG Vial 61,996.00 - - - - - -
322 Campak + Pelarut Campak Vial 28,204.00 - - - - - -
323 DPT-HB-Hib Vial 78,991.00 - - - - - -
324 DT Vial 17,996.00 - - - - - -
325 Hepatits B Buah 23,991.00 - - - - - -
326 IPV Vial 139,760.00 - - - - - -
327 IPV Vial 144,540.00 - - - - - -
328 MR Vial 141,648.00 - - - - - -
329 Polio+ Dropper Polio Vial 19,954.00 - - - - - -
330 Td Vial 16,995.00 - - - - - -
ANTI RABIES - - - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - 3 3 - -
Page 12
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT FILARIASIS - - - -
332 Albendazol 400 mg tablet 258.74 - - - - - -
OBAT GIZI - - - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - 28,000 - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 100 - 100 100 - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 350 - 350 350 - -
OBAT MALARIA - - - -
336 Blood Slide Kotak 18,509.00 7 - 7 7 - -
337 DHP Frimal tablet 3,498.00 - - - - - -
338 Kelambu GF Buah 61,077.00 - - - - - -
339 Primaquin 15 mg tablet 235.00 - - - - - -
OBAT KIA IBU - - - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - - -
342 Euthyrox 50 mcg tablet 735.00 - - - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - 10 10 10 - -
344 Methylergometrin Injeksi ampul 3,102.00 15 - 15 15 - -
345 MgSO4 20 % fls 3,328.00 - - - - - -
346 MgSO4 40 % fls 3,796.00 - - - - - -

OBAT KIA ANAK - - - -
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 - 25 20 - -
OBAT TB PARU - - - -
350 Box Slide Kotak 41,342.00 - - - - - -
351 Kaca Slide Kotak 30,000.00 - - - - - -
352 Kaca Slide Kotak 20,747.00 - - - - - -
353 OAT Kategori Anak Paket 232,518.00 - - - - - -
354 OAT Kategori I Paket 377,900.00 3 - 3 3 - 6 - -
355 OAT Kategori II Paket 1,259,990.00 - - - - - -
356 Pot Sputum Pot 2,500.00 - - - - - -
Page 13
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
357 Reagen Ziehl Neelsen Kit 276,000.00 14 - 14 14 - -
358 Sputum Pot Buah 2,950.00 1,276 - 1,276 1,220 - -
359 Tuberkulin Vial 625,900.00 - - - - - -
KUSTA - - - -
360 MDT PB Dewasa Blister 12,569.00 - - - - - -
ALAT DETEKSI RESIKO KEHAMILAN -

-
- -
361 Paket ADRK II Paket 422,980.00 - - - - - -

IMUNISASI - - - -
362 ADS 0,05 ml Buah 1,518.00 - - - - - -
363 ADS 0,5 (Oneject) Buah 1,621.00 71 - 71 71 - -
364 ADS 0,5 ml Buah 1,127.00 - - - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - - -
369 ADS 5 ml buah 1,705.00 30 - 30 30 - -
370 ADS 5 ml Buah 1,705.00 - - - - - -
371 ADS 5 ml Buah 1,439.00 - - - - - -
372 ADS 5 ml Buah 1,500.00 - - - - - -
373 RCW Unit 2,266,454.00 - - - - - -
374 Safety Box pcs 16,608.00 - - - - - -
375 Safety Box 2,5 ml Buah 12,500.00 - - - - - -
376 Safety Box 5 ml Buah 20,394.00 - - - - - -
377 Vaccine Carrier buah 1,870,000.00 - - - - - -
OBAT FLU BURUNG - - - -
378 Oseltamivir kapsul 12,969.00 - - - - - -
OBAT DIARE - - - -
379 Garam Oralit Sachet 257.00 137 - 137 - - -
380 Garam Oralit Sachet 253.00 100 - 100 - - -
381 Zink Tablet tablet 551.00 1,300 - 1,300 100 - -
OBAT HIV/AIDS - - - -
382 Rapid 1 : SD HIV test 11,975.00 80 - 80 80 - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - - -
Page 14
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
384 Rapid Sifilis Ab test 20,400.00 - - - - - -
385 RPR Sifilis test 4,250.00 - - - - - -
OBAT HEPATITIS - - - -
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - - -
Reagensia/ Alat - - - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - - - -
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - - -
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - - -
391 Rapid 3 Diagnostar test 13,771.00 - - - - - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - - -
393 Rapid Sifilis Trepocheck test 9,697.00 - 50 50 50 - -
394 RPR Sifilis test 4,250.00 - - - - - -
SUMBER DANA APBD II - - - -
OBAT KATARAK - - - -
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 1 - 1 1 - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - - - -
OBAT PROGRAM - - - -
397 L- Zinc botol 31,350.00 12 - 12 6 20 - -
398 Lagesil Suspensi botol 40,755.00 4 - 4 3 20 - -
REAGENTIA - - - -
399 Objek Gelas Kotak 50,000.00 3 - 3 3 - -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - - -
REAGENSIA - - - -
401 Larutan Alkohol 96% botol 242,000.00 - - - - - -
402 Larutan Metanol botol 665,500.00 - - - - - -
403 Reagen Benedict botol 484,000.00 - - - - - -
404 Reagen Natrium Sitrat botol 514,250.00 - - - - - -
405 Reagen Receker botol 2,238,500.00 - - - - - -
406 Reagensia Asam Asetat botol 544,500.00 - - - - - -
407 Slide test widal Unit 302,500.00 - - - - -

-
BELANJA STICK NARKOBA - - - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - - -
Page 15
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - - -
PENINGKATAN KESEHATAN MASYARAKAT - - - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 -

-
- - - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - -

-
18 18 - -
DHP Frimal tablet 2,134.00 9 9
Asam Askorbat (Vit C) tab 50 mg tablet 110.00
- 1,000
1,000 1,000 3,000 1000 1,000 110,000
Lysol 1 liter botol 81,250.00

- 10 10 10 40 40 40 3,250,000
Alkohol 1 L Bottle 230,000.00 - 5 5 5 - -
One Med Povidone Iodine 30 ml botol 3,680.00 - 10 10 10 7 - -

Fokus Diagnostis Syphilis Test 13,900.00 - 50 50 50 - -
Fokus New HIV 1/2 Test 13,235.00

- 500
500 500 - -
Ringer Laktat/Ringer Lactate 500 ml botol 7,630.000 20 20 20 152,600
Paracetamol/ Parasetamol sirup 120 mg / 5 ml bottle 1,181.00 50 50 50 59,050
Masker box 450,000.00 5 5 5 2,250,000

tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 500 500 500 53,000
strip/blister (G) selaput
One Med Povidone Iodine 60 ml botol 5,186.50 7 7 7 36,306
27,167,921.20
Diketahui: Diketahui: Yang Menyerahkan Diketahui : Yang Menerima

Kepala Dinas Kesehatan Kabid. Sumber Daya Kesehatan Kasie Farmasi Kepala Puskesmas Pengelola obat
Kab.Labuhanbatu Utara
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr.Ferani Nasution Siti Aisyah
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 NIP.19841127 201101 2 002 Nip.19880405 201101 2 006
Page 16
0
0
0
0
100
500
0
0
0
0
600
960
10
200
50
60
0
0
0
1500
Page 17
0
100
25
24
0
0
0
500
0
0
0
16
0
25
0
24
0
0
0
0
0
50
0
Page 18
0
0
30
0
0
0
0
0
0
0
0
2000
0
0
0
0
0
0
0
0
Page 19
0
0
0
0
0
0
0
0
0
100
30
0
0
0
0
500
0
0
0
0
24
0
Page 20
50
1200
0
0
0
50
0
0
300
0
0
0
200
0
0
0
0
0
0
1000
300
0
0
200
0
Page 21
300
0
200
0
0
0
0
0
0
0
0
24
20
0
0
200
0
0
0
0
0
200
0
0
Page 22
1500
20
0
100
0
0
500
0
0
200
0
0
500
500
0
200
5
500
50
0
0
0
20
0
0
0
Page 23
0
0
0
24
0
0
0
0
0
0
200
0
0
2000
0
0
0
0
0
Page 24
2000
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 25
0
0
0
0
0
0
0
0
0
2
0
0
5
0
0
0
0
0
0
0
0
0
20
20
20
20
20
0
5
5
Page 26
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
0
0
0
0
0
Page 27
0
0
0
0
0
0
0
0
0
0
0
14
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 28
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 29
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 30
0
0
0
0
0
0
0
0
0
0
0
50
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 31
0
1000
10
10
5
50
500
Page 32
DINKES
PUSKESMAS : BELONGKUT LAPORAN TRIWULAN : I (II) III IV GFK 17/IFK/3/2020 29-Sep-20
KECAMATAN : MARBAU PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 1,070 - 1,070 70 1,000 2,000 - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 911 911 200 200 200 210,000.00
3 Alopurinol tablet 100 mg tablet 97.00 1,424 500 1,924 1,355 569 2,500 2,000 2,000 194,000.00
4 Alopurinol tablet 100 mg tablet 104.00 - - - -
5 Ambroxol 15 mg/5 ml botol 6,600.00 - 100 100 65 35 150 - -
6 Ambroxol tab 30 mg tablet 330.00 1,360 1,000 2,360 1,430 930 2,500 2,500 2,500 825,000.00
7 Aminofilin inj 24 mg/ml ampul 2,998.00 - - - -
8 Aminofilin tablet 200 mg tablet 92.00 410 - 410 240 170 - - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 - - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 1,106 600 1,706 276 1,430 7,200 7,200 7,200 525,600.00
11 tablet 78.00 - - - -
12 Kaplet 94.00 - - 900 900 900 84,600.00
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 40 50 90 90 - 200 14 14 92,400.00
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 106 60 166 120 46 150 120 120 440,400.00
17 kaptab 261.00 2,084 5,000 7,084 6,728 356 10,000 5,000 5,000 1,305,000.00
500 mg, kemasan strip/blister (G)
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - -
19 Antasida Tablet box 5,594.00 - - - -
20 Antasida Tablet tablet 200.00 - - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
21 Antasida Tab Tablet 355.00 - - - -

22 tablet 60.00 3,451 - 3,451 2,574 877 8,000 5,000 5,000 300,000.00
200 mg + Magnesium Hidroksida 200 mg
23 botol 2,189.00 250 50 300 20 280 200 150 150 328,350.00

+ Polimiksin 10.000
3,071.00
IU/g - - - -

25 pot 4,540.00 - - - -
Asam Salisilat 3%
Antihemoroid, Kombinasi sup: bismut subgalat supposito

26 3,325.00 - - - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 1,980 480 2,460 2,380 80 200 - -
31 Asiklovir Cream Tube - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 70 70 70 - - -
33 Bedak salisil serbuk 2% dus 1,040.00 - - - - -
34 Bedak Salisil Kotak 8,000.00 - - 50 30 30 240,000.00
35 Betametason krim 0,5 mg/g tube 3,388.00 145 25 170 22 148 100 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - 50 50 50 67,000.00
37 Ampul 130,999.00 - - - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - - - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 500 72 572 35 537 100 - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - 288 288 288 903,744.00
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 2,880 - 2,880 - 2,880 3,000 - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
46 Cetirizin Hydrochloride salut 94.00 533 1,290 1,823 - 1,823 5,000 - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - - 500 500 500 50,500.00
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 38 100 138 - 138 50 - -
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 977 - 977 94 883 500 500 500 330,000.00
tablet
50 salut 165.00 - - - -
selaput
51 kapsul 770.00 540 700 1,240 723 517 1,500 1,500 1,500 1,155,000.00
52 Codeine 10 mg tablet 600.00 - - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 108 100 208 208 - 200 50 50 109,500.00
trimetoprim 40 mg (susp 240 mg)

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 3,015 200 3,215 3,215 - 5,000 700 700 93,100.00
mg (tab/kaptab 480 mg)
56 tablet 47.00 - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 250 100 350 316 34 240 240 240 276,480.00
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 1,457 800 2,257 1,132 1,125 5,000 - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - 500 500 500 77,000.00
61 Dekstrofen Syrup Botol 11,550.00 269 50 319 30 289 200 - -
62 Diazepam 2 mg Tablet 86.00 70 - 70 20 50 - - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 10 - 10 10 - 10 10 10 18,220.00
65 Diclofenac Sodium 25 mg Tablet 141.00 - 700 700 470 230 1,000 - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - 2,800 2,800 130 2,670 5,600 5,600 5,600 761,600.00
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - 30 30 20 10 100 90 90 103,590.00

69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 224 - 224 224 - - -
70 Digoksin tablet 0,25 mg tablet 106.00 - - - -
71 Digoksin 0,25 mg Tablet 104.00 - - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 1,478 - 1,478 77 1,401 - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 195 50 245 130 115 100 50 50 139,050.00
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 - - - -
75 Domperidon tablet 10 mg tablet 86.00 - 2,400 2,400 1,485 915 4,000 2,000 2,000 172,000.00
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - - - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 50 - 50 - 50 - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 1,870 - 1,870 1,860 10 3,000 1,600 1,600 1,224,000.00
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 194 - 194 194 - 50 - -
83 Eugenol cairan botol 21,091.00 - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 - - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - -
87 tablet 747.00 140 - 140 140 - 500 - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 200 300 500 230 270 300 300 300 239,100.00
89 ampul 3,867.00 - 30 30 28 2 50 - -
mg/ml
90 Fituno Tab tablet 4,163.10 - - - -
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - -
92 Furosemide tablet 40 mg tablet 77.00 - - - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 100 - 100 - 100 - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 9 5 14 14 - 100 10 10 28,100.00
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 9 5 14 14 - 100 10 10 44,520.00
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 3,202 1,000 4,202 3,877 325 2,000 1,500 1,500 187,500.00
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 32 20 52 25 27 50 - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 1,448 500 1,948 1,230 718 500 500 500 122,500.00
99 Griseofulvin tablet 125 mg tablet 232.00 - - - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - -
101 Haloperidol 0,5 mg Tablet 55.00 - - - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - 100 100 100 16,300.00
103 Hidrokortison krim 2,5 % tube 2,640.00 256 24 280 185 95 100 - -
104 Hidrokortison krim 2,5% tube 2,475.00 - - 72 72 72 178,200.00
105 Hustab Syrup botol 11,550.00 420 150 570 480 90 200 100 100 1,155,000.00
106 Hustab P Tablet 8 mg Tablet 256.67 7,976 600 8,576 4,743 3,833 3,000 3,000 3,000 770,010.00
107 Hustab Tablet tablet 437.00 435 900 1,335 888 447 3,600 3,600 3,600 1,573,200.00
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - - - -
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 - - - -
selaput
110 Ibuprofen 200 mg Tablet 550.00 1,100 500 1,600 60 1,540 500 300 300 165,000.00
111 Ibuprofen 400 mg Tablet 800.00 - 500 500 170 330 2,000 500 500 400,000.00
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 66 50 116 87 29 50 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - 50 50 50 138,800.00
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 468 - 468 - 468 - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - -

116 tablet 63.00 2,976 1,000 3,976 3,036 940 1,500 1,500 1,500 94,500.00
117 Kanamycin 1 gr inj vial 10,768.00 - - - -
118 Kaptopril 12,5 mg tablet 68.00 234 1,000 1,234 1,234 - 500 500 500 34,000.00
119 Ketokenazol tablet 200 mg tablet 278.00 783 - 783 783 - 1,500 - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
120 Ketokonazol tablet 200 mg tablet 297.00 - - - -

121 Kloramfenicol kapsul 250 mg Capsule 320.00 345 1,000 1,345 913 432 400 - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - - -
123 Kloramfenikol Salep 2% tube 3,349.00 - - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 37 48 85 57 28 50 24 24 48,168.00
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 124 - 124 124 - 100 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - 50 50 43 7 100 100 100 516,800.00
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 9,497 - 9,497 8,783 714 1,500 - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - -
129 Klorfeniramin maleat tablet 25.00 - 1,500 1,500 1,500 - 5,000 5,000 5,000 125,000.00
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 400 400 400 - 1,000 - -
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 640 - 640 640 - 400 400 400 513,500.00
132 Lidocaine Injeksi 2 % ampul 1,203.00 67 100 167 133 34 50 - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 432 500 932 932 - 2,000 300 300 78,000.00
134 Meloksikam 7,5 mg tablet 795.68 765 - 765 705 60 1,000 - -
135 Mercybion Ampul 4,840.00 - - - -
136 Meloxicam 15 mg Tablet 980.00 - 2,000 2,000 2,000 - 500 500 500 490,000.00
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 320 500 820 540 280 1,000 - -
138 tablet 137.00 256 1,800 2,056 1,887 169 5,000 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - - 2,000 2,000 2,000 292,000.00
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - - - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 - - - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 690 500 1,190 320 870 - - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - 30 30 14 16 100 20 20 79,000.00
146 Metronidazole tablet 500 mg tablet 264.00 1,016 1,500 2,516 2,226 290 2,000 700 700 184,800.00
147 MgSO4 20 % botol 13,500.00 - - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
148 MgSO4 40 % botol 13,500.00 - - - -

149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 - - - -
150 NaCl 0,9 % 500 ml botol 6,840.00 - - - -
151 tablet 132.00 698 698 448 250 1,000 - -
25 mg
152 tablet 127.00 1,777 473 2,250 - 2,250 - - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 380 200 580 490 90 300 - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 1,788 - 1,788 1,548 240 1,000 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - 500 500 500 - 200 200 200 177,200.00
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - 10 10 5 5 5 - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - 2 2 2 - - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - -
161 Omeprazol Tab Tablet 650.00 400 400 355 45 3,000 200 200 130,000.00
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - - - -
163 Paracetamol Tab 500 mg tablet 290.00 - - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 2,632 5,200 7,832 5,547 2,285 7,000 5,200 5,200 858,000.00
165 bottle 6,981.00 - - - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - - - -
167 Pehacain Injeksi ampul 3,113.06 158 300 458 268 190 50 - -
168 Pehacain Injeksi Ampul 3,113.05 - - 100 100 100 311,305.00
169 Pehamoksil Tablet 500 mg Tablet 759.00 2,020 2,020 2,020 - 5,000 - -
170 Pehastan 500 mg tablet 445.50 190 6,000 6,190 6,190 - 6,000 3,600 3,600 1,603,800.00
171 Pehavral tablet 935.00 - - - -
172 Perak sulfadiazin krim 1% tube 20,700.00 - - - -
173 Peridol Syrup 60 ml botol 19,800.00 - - - -
174 botol 124,355.00 - 24 24 24 - 150 2 2 248,710.00
0,2 %
175 Phenol glyserol tts Telinga botol 2,590.00 - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
176 Phaproxin 500 mg tablet 880.00 420 1,500 1,920 1,920 - 4,000 1,800 1,800 1,584,000.00
177 tablet 302.00 - - - -
mg
178 Pirantel pamoat 125 mg tab tablet 322.00 - 200 200 - 200 - - -
179 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - - - -
180 Pirantel Pamoat syrup botol 10,778.00 - - - -
181 Tablet 124.00 5,465 - 5,465 5,455 10 1,000 - -
(HCl)
182 tablet 129.00 1,530 300 1,830 1,830 - 2,000 2,000 2,000 258,000.00
(HCl)
183 Prednison tablet 5 mg tablet 76.00 1,864 800 2,664 2,494 170 4,000 1,000 1,000 76,000.00
184 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 - - - -
185 Pularex Attapulgit tab 630 mg tablet 142.00 712 500 1,212 1,043 169 2,000 100 100 14,200.00
186 Pyridol Syrup 60 ml botol 18,150.00 168 - 168 118 50 200 - -
187 Ranitidin 150 mg Tablet tablet 660.00 1,778 3,000 4,778 3,093 1,685 8,000 1,000 1,000 660,000.00
188 Ranitidin 50 mg/2 ml inj ampul 1,531.00 89 100 189 150 39 100 100 100 153,100.00
189 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 - - - -
190 Retinol/ Vit A 100.000 UI capsule 304.00 - - - -
191 Retinol/ Vit A 200.000 UI capsule 543.99 - - - - -
192 Ringer Laktat 500 ml botol 7,630.00 255 100 355 - 355 60 - -
193 Roeko Endo Frost 200 ml botol 352,000.00 - - - -
194 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 1,245 1,245 1,155 90 200 200 200 12,600.00
195 Salbutamol 2 mg tab tablet 67.00 - - - -
196 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 500 100 600 530 70 1,000 1,000 1,000 80,000.00
197 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - -
198 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - - -
199 pot 2,654.00 - - - -
endap 4%
200 Sefadroksil kapsul 500 mg Kapsul 1,210.00 889 500 1,389 1,389 - 5,000 - -
201 Seftriakson serb inj 1.000 mg vial 4,998.00 5 5 5 - - - -
202 Setrizin sirup 5 mg/5 ml bottle 2,907.00 214 18 232 - 232 - - -
Tablet
203 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - - - -
Selaput
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
204 Simvastatin tablet 10 mg Tablet 117.00 - - 1,680 1,680 1,680 196,560.00

tablet
205 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 - - - -
selaput
206 Stesolid 5 mg/ 2,5 ml tube 13,202.00 5 5 3 2 - - -
208 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 725 725 295 430 1,000 - -
209 tablet 84.00 - - - -
(HCL/Nitrat)
210 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - 400 400 250 150 300 300 300 25,800.00
tablet
211 salut 93.00 - - - -
selaput
212 Vapril 25 mg tablet 193.00 1,570 500 2,070 800 1,270 - - -
213 box 6,550.00 - - - -
mcg/kapsul)
214 Vitamin B Kompleks tablet 123.00 4,115 500 4,615 2,640 1,975 2,000 1,000 1,000 123,000.00
215 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 111 200 311 186 125 3,000 100 100 113,600.00
216 Vitamin B12 tablet 50 mcg tablet 52.00 3,100 500 3,600 3,430 170 2,000 2,000 2,000 104,000.00
217 Vitamin B12 tablet 50 mcg tablet 50.00 - - - -
218 Vitamin B6 10 mg tablet 138.00 - - - - -
219 9,646.00 - - - - -
plabot Plastik
220 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 25 25 25 100 - -
OBAT GIZI (DAK 2019) - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - 28,000 28,000 14,400 13,600 - - -
221 Hemafort tablet 834.90 3,688 7,200 10,888 6,148 4,740 7,200 7,200 7,200 6,011,280.00
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 20 40 60 60 10 - -
chloride, zinc acetate)
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - -
224 Kapsul 581.00 - - - -
IU
BAHAN MEDIS HABIS PAKAI (DAK ) - -
225 Alkohol Swab pcs 110.00 1,335 25 1,360 360 1,000 200 - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
226 Alkohol 70% 1L botol 28,750.00 12 6 18 6 12 15 - -
227 Arm sling L buah 17,424.00 - - - -
228 Arm sling M buah 17,424.00 - - - -
229 Arm sling S buah 17,424.00 - - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 6 2 8 2 6 20 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 10 5 15 15 - - -
232 Aximed Syringe 1 cc Dus 103,750.00 - - - -
233 Aximed Syringe 3 cc Dus 103,125.00 7 10 17 12 5 11 11 11 1,134,375.00
234 Blood Lancet box 16,022.60 - 5 5 3 2 5 - -
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 - - 24 24 24 834,480.00
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - - - -
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 66 - 66 66 - 50 12 12 481,648.80
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - 48 48 35 13 50 24 24 872,160.00
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 4 48 52 28 24 50 - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 4 4 4 - 50 - -
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - 50 50 26 24 24 - -
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 - - - -
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - -
255 Dermafix T 10x12cm pcs 6,939.90 9 6 15 5 10 - - -
256 Examination Gloves size L box 58,564.00 - 3 3 3 - 3 3 3 175,692.00
257 Examination Gloves size M box 58,564.00 - 3 3 3 - 3 3 3 175,692.00
258 Examination Gloves size S box 58,564.00 - - - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - 5 5 - 5 5 5 5 187,200.00
260 Folley catheter 2 way no. 16 pcs 8,800.00 16 2 18 - 18 - - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - 50 - -
262 Germany Tro-Sensosurge Steril Glove 7.5 pasang 7,254.00 40 20 60 50 10 50 - -
263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 - - - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - -
267 Hb Sahli set 96,800.00 - - - -
268 Hidrogen Peroxide 3% botol 3,864.00 - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 4 - 4 - 4 100 - -
270 Infuset pcs 6,166.16 25 10 35 20 15 50 50 50 308,308.00
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - 20 20 10 10 50 20 20 163,301.60
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 28 50 78 50 28 30 30 30 242,665.50
273 IV- Cath WP, with wings & port no 24 pcs 8,088.85 - - - -
275 Kapas pembalut 250 gr roll 13,733.33 - - - -
276 Kapas pembalut 250 gr roll 13,750.00 2 20 22 12 10 20 5 5 68,750.00
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - - - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 110 100 210 200 10 100 100 100 176,000.00
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 60 100 160 110 50 100 100 100 165,000.00
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - - -
282 Lysol 1 liter botol 47,150.00 - - - -
282 Leokoplast Hospital 2,5 cm x 4,5 cm Roll 12,076.00 - - - -
282 Masker Ear Loop Box 20,202.00 - - - -
282 Masker Tie on Box 19,869.00 5 5 - 5 50 - -
282 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - -
282 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - 5 5 - 5 - - -
282 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - 5 5 - 5 - - -
282 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - -
282 Onemed Alcohol Swab botol 11,000.00 - - 2 2 2 22,000.00
282 Onemed Blood Lancet box 16,022.60 - 5 5 2 3 5 5 5 80,113.00
282 Onesept 500 ml botol 30,360.00 - - - -
282 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 - - - -
282 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - -
282 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - - - -
282 Safeglove Examination Gloves L box 39,182.00 - - - -
282 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - 5 5 - 5 10 5 5 106,425.00
282 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - -
282 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - -
282 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - -
282 Stera Infuset anak pcs 3,850.00 16 - 16 12 4 15 - -
282 Surgical Mask Earloop box 18,150.00 - - - -
282 Surgical Mask Tie On box 18,150.00 - 10 10 10 - 10 - -
282 Swab 2 ply dus 14,040.84 - - - -
282 Syringe 10 cc dus 167,266.70 - - - -
282 Syringe 1cc pcs 1,045.80 - 100 100 60 40 - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
282 Syringe 1cc dus 106,523.56 - - - -
282 Syringe 3cc dus 107,421.38 - - - -
282 Syringe 5cc dus 119,090.61 50 50 20 30 50 - -
282 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - -
282 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - -
282 TP. Disposable Syringe 3 cc pcs 750.39 - - - -
282 Tp. Disposable Syringe 5 cc pcs 892.78 - - - -

282 pcs 7,072.50 - - 15 15 15 106,087.50
Airvent, Luer Lock
282 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - -
282 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - -
282 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - -
282 Povidone Iodine 10% 30 ml Botol 3,335.00 40 - 40 20 20 50 - -
282 Rivanol 300 cc Botol 3,450.00 - - - -
282 Urine bag steril (t-valve) pcs 3,300.00 21 - 21 - 21 - - -
PEMERIKSAAN HIV - -
319 HIV Device Box 707,143.00 - - - -
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS - -
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - - - -
SUMBER DANA APBD I - -
VAKSIN - -
321 BCG +Pelarut BCG Vial 61,996.00 - - - -
322 Campak + Pelarut Campak Vial 28,204.00 - - - -
323 DPT-HB-Hib Vial 78,991.00 - - - -
324 DT Vial 17,996.00 - - - -
325 Hepatits B Buah 23,991.00 - - - -
326 IPV Vial 139,760.00 - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
327 IPV Vial 144,540.00 - - - -
328 MR Vial 141,648.00 - - - -
329 Polio+ Dropper Polio Vial 19,954.00 - - - -
330 Td Vial 16,995.00 - - - - -
ANTI RABIES - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - -
OBAT FILARIASIS - -
332 Albendazol 400 mg tablet 258.74 - - - - -
OBAT GIZI - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - -
OBAT MALARIA - -
336 Blood Slide Kotak 18,509.00 - 5 5 - 5 - - -
337 DHP Frimal tablet 3,498.00 - - - - -
338 Kelambu GF Buah 61,077.00 - - - - -
339 Primaquin 15 mg tablet 235.00 - - - - -
OBAT KIA IBU - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - 10 10 - 10 - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - -
342 Euthyrox 50 mcg tablet 735.00 - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - 30 30 10 20 - - -
344 Lidocaine Injeksi 2 % ampul - - - -
345 Vit K (Neo K) ampul - - - -
346 Abocat No. 16 pcs - - - -
347 Abocat No. 18 pcs - - - -
348 Epinephrin 0,1% ampul - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
349 Meterghin ampul - - - -
350 Methylergometrin Injeksi ampul 3,102.00 50 - 50 30 20 - - -
351 MgSO4 20 % fls 3,328.00 20 - 20 - 20 - - -
352 MgSO4 40 % fls 3,796.00 20 - 20 - 20 - - -
OBAT KIA ANAK - -
353 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - -
354 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - -
355 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - 27 27 22 5 - - -
OBAT TB PARU - -
356 Box Slide Kotak 41,342.00 - - - -
357 Kaca Slide Kotak 30,000.00 - - - -
358 Kaca Slide Kotak 20,747.00 - - - -
359 OAT Kategori Anak Paket 232,518.00 - - - -
360 OAT Kategori I Paket 377,900.00 - - - -
361 OAT Kategori II Paket 1,259,990.00 - - - -
362 Pot Sputum Pot 2,500.00 - 1,000 1,000 100 900 - - -
363 Reagen Ziehl Neelsen Kit 276,000.00 - 14 14 - 14 - - -
364 Sputum Pot Buah 2,950.00 - - - -
365 Tuberkulin Vial 625,900.00 - - - -
KUSTA - - - -
366 MDT PB Dewasa Blister 12,569.00 - - - - -
ALAT DETEKSI RESIKO KEHAMILAN - - - -
367 Paket ADRK II Paket 422,980.00 - - - - -
IMUNISASI - - - -
368 ADS 0,05 ml Buah 1,518.00 - - - - -
369 ADS 0,5 (Oneject) Buah 1,621.00 - - - - -
370 ADS 0,5 ml Buah 1,127.00 - - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
371 ADS 0,5 ml Buah 1,090.00 - - - - -
372 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - -
373 ADS 0,5 ml SKIFA buah 1,240.00 - - - - -
374 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - -
375 ADS 5 ml buah 1,705.00 - - - - -
376 ADS 5 ml Buah 1,705.00 - - - - -
377 ADS 5 ml Buah 1,439.00 - - - - -
378 ADS 5 ml Buah 1,500.00 - - - - -
379 RCW Unit 2,266,454.00 - - - - -
380 Safety Box pcs 16,608.00 - - - - -
381 Safety Box 2,5 ml Buah 12,500.00 - - - - -
382 Safety Box 5 ml Buah 20,394.00 - - - - -
383 Vaccine Carrier buah 1,870,000.00 - - - - -
384 Oseltamivir kapsul 12,969.00 - - - - -
OBAT DIARE - - - -
385 Garam Oralit Sachet 257.00 - - - -
387 Zink Tablet tablet 551.00 - 500 500 - 500 500 500 500 275,500.00
388 Rapid 1 : SD HIV test 11,975.00 - - - -
389 Rapid 2 : Focus Diagnostic test 13,615.00 - - - -
390 Rapid Sifilis Ab test 20,400.00 - - - -
391 RPR Sifilis test 4,250.00 - - - -
392 HB Imuno Globulin Kotak 1,325,000.00 - - - -
393 Rapid Test SD Bioline HBsAg test 9,870.00 - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
394 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - 200 200 10 190 - - -
395 Rapid 2 HIV (Focus) test 13,615.00 - - - -
396 Rapid 2 HIV (KHB) test 12,500.00 - - - -
397 Rapid 3 Diagnostar test 13,771.00 - - - -
398 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - -
399 Rapid Sifilis Trepocheck test 9,697.00 - 50 50 - 50 - - -
400 RPR Sifilis test 4,250.00 - - - -
401 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - -
402 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - -
403 L- Zinc botol 31,350.00 - - - -
404 Lagesil Suspensi botol 40,755.00 - - - -
REAGENTIA - - - -
405 Objek Gelas Kotak 50,000.00 - - - -
406 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - -
REAGENSIA - - - -
407 Larutan Alkohol 96% botol 242,000.00 - - - -
408 Larutan Metanol botol 665,500.00 - - - -
409 Reagen Benedict botol 484,000.00 - - - -
410 Reagen Natrium Sitrat botol 514,250.00 - - - -
411 Reagen Receker botol 2,238,500.00 - - - -
412 Reagensia Asam Asetat botol 544,500.00 - - - -
413 Slide test widal Unit 302,500.00 - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
414 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - 1 1 - 1 - - -
415 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - -
416 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - -
417 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - -

tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 500 500 500 -
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1,000 1,000 1,000 110,000.00
One Med Povidone Iodine 60 ml botol 5,186.50 20 20 20 103,730.00
Masker box 450,000.00 10 10 10 4,500,000.00
Ringer Laktat/Ringer Lactate 500 ml botol 7,630.000 60 60 60 457,800.00
Paracetamol/ Parasetamol sirup 120 mg / 5 ml bottle 1,181.00 50 50 50 59,050.00
Lysol 1 liter botol 82,150.00 60 60 60 4,929,000.00
Glukosa Larutan Infus 5 % 500 ml botol 7,363.000 20 20 20 147,260.00
Aseptic Gel Antiseptic pembersih tangan botol 30,475.000 20 20 20 609,500.00
TOTAL 46,733,025

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr. Darma Barus Juliani
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip.19770809 200604 1 003 Nip. 19770710 201408 2 004
- 0
- 0
500.00 500
- 100
100.00 1000
1,000.00 0
- 0
- 0
- 0
- 600
600.00 0
- 0
- 0
- 50
50.00 60
60.00 5000
5,000.00 0
- 0
- 0
- 3000
3,000.00 0
- 50
50.00 0
- 0
- 0
- 0
- 0
- 0
- 400
400.00 0
- 0
- 0
- 0
- 0
- 25
25.00 0
- 0
- 0
- 0
- 72
72.00 0
- 0
- 0
- 0
- 0
- 1000
1,000.00 100
100.00 0
- 0
- 700
700.00 0
- 0
- 100
100.00 200
200.00 0
- 100
100.00 0
- 800
800.00 0
- 50
50.00 0
- 0
- 0
- 700
700.00 2800
2,800.00 0
- 30
30.00 0
- 0
- 0
- 0
- 50
50.00 0
- 2400
2,400.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 300
300.00 30
30.00 0
- 0
- 0
- 0
- 5
5.00 5
5.00 1000
1,000.00 20
20.00 500
500.00 0
- 0
- 0
- 0
- 24
24.00 0
- 100
100.00 600
600.00 900
900.00 0
- 0
- 500
500.00 500
500.00 0
- 50
50.00 0
- 0
- 1000
1,000.00 0
- 1000
1,000.00 0
- 0
- 0
- 1000
1,000.00 0
- 48
48.00 0
- 50
50.00 0
- 0
- 1500
1,500.00 400
400.00 0
- 100
100.00 500
500.00 0
- 0
- 2000
2,000.00 500
500.00 1800
1,800.00 0
- 0
- 0
- 0
- 0
- 500
500.00 30
30.00 1500
1,500.00 0
- 0
- 0
- 0
- 0
- 0
- 200
200.00 0
- 500
500.00 0
- 0
- 0
- 2
2.00 0
- 400
400.00 0
- 0
- 5200
5,200.00 0
- 0
- 0
- 300
300.00 0
- 6000
6,000.00 0
- 0
- 24
24.00 0
- 0
- 1500
1,500.00 0
- 200
200.00 0
- 0
- 0
- 300
300.00 800
800.00 0
- 500
500.00 0
- 3000
3,000.00 100
100.00 0
- 0
- 0
- 100
100.00 0
- 0
- 200
200.00 100
100.00 0
- 0
- 0
- 500
500.00 0
- 0
- 0
- 300
300.00 0
- 0
- 0
- 400
400.00 0
- 500
500.00 0
- 500
500.00 200
200.00 500
500.00 0
- 0
- 0
- 0
- 0
- 28000
28,000.00 7200
7,200.00 40
40.00 0
- 0
- 0
- 25
25.00 0
- 0
- 0
- 0
- 0
- 0
- 10
10.00 5
5.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 48
48.00 0
- 0
- 48
48.00 0
- 0
- 50
50.00 0
- 0
- 0
- 0
- 0
- 0
- 3
3.00 3
3.00 0
- 5
5.00 0
- 0
- 20
20.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 10
10.00 20
20.00 50
50.00 0
- 0
- 0
- 20
20.00 10
10.00 100
100.00 100
100.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 5
5.00 5
5.00 0
- 0
- 5
5.00 0
- 0
- 0
- 0
- 0
- 5
5.00 0
- 0
- 0
- 0
- 0
- 10
10.00 0
- 0
- 100
100.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 14
14.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 5
5.00 0
- 0
- 0
- 0
- 10
10.00 0
- 0
- 30
30.00 0
- 0
- 0
- 0
- 0
- 0
- 27
27.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 1000
1,000.00 14
14.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 500
500.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 200
200.00 0
- 0
- 0
- 0
- 50
50.00 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 1
1.00 0
- 0
- 0
- 0
- 10
10.00 10
10.00 36
36.00 1000
1,000.00 50
50.00 350
350.00 9
9.00 10
10.00 5
DINKES
PUSKESMAS : KUALA BANGKA LAPORAN TRIWULAN : I (II) III IV GFK 16/IFK/3/2020 25-Sep-20
KECAMATAN : KUALUH HILIR PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - -
3 Alopurinol tablet 100 mg tablet 97.00 200 1000 1200 800 400 700 700 700 67,900
4 Alopurinol tablet 100 mg tablet 104.00 - -
5 Ambroxol 15 mg/5 ml botol 6,600.00 100 100 100 660,000
6 Ambroxol tab 30 mg tablet 330.00 2000 2000 1000 1000 800 800 800 264,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 10 10 - -
8 Aminofilin tablet 200 mg tablet 92.00 - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 - -
11 tablet 78.00 200 200 - -
12 Kaplet 94.00 - -
13 Amoksisilin 100 mg/mL botol 13,500.00 - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 - -
17 kaptab 261.00 300 300 1500 1500 1,500 391,500
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - -
19 Antasida Tablet box 5,594.00 - -
20 Antasida Tablet tablet 200.00 200 200 - -
21 Antasida Tab Tablet 355.00 2000 2000 1000 1000 1500 1500 1,500 532,500
Page 69
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
22 tablet 60.00 - -
23 botol 2,189.00 100 100 100 218,900

+ Polimiksin 10.000
3,071.00
IU/g - -

25 pot 4,540.00 - -
Asam Salisilat 3%

26 3,325.00 - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - -
28 Asam Mefenamat 500 mg tablet 242.89 - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 200 200 500 - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - -
33 Bedak salisil serbuk 2% dus 1,040.00 - -
34 Bedak Salisil Kotak 8,000.00 - -
35 Betametason krim 0,5 mg/g tube 3,388.00 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - -
37 Ampul 130,999.00 - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - -
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 1000 - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - -
tablet
46 Cetirizin Hydrochloride salut 94.00 - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - -
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 - -
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - -
Page 70
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
50 salut 165.00 - -
selaput
51 kapsul 770.00 500 500 500 385,000
52 Codeine 10 mg tablet 600.00 - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 10 10 10 40 - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 50 50 50 109,500
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 700 700 300 400 500 500 500 66,500
56 tablet 47.00 - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 480 480 140 340 - -
mg/ml
58 Dexamethason inj Ampul 4,500.00 - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 3000 3000 2500 500 2000 - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - -
61 Dekstrofen Syrup Botol 11,550.00 - -
62 Diazepam 2 mg Tablet 86.00 - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 - -
65 Diclofenac Sodium 25 mg Tablet 141.00 500 500 500 1000 1000 1,000 141,000
66 Diclofenac Sodium 50 mg Tablet 136.00 - -
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 30 30 30
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - -
70 Digoksin tablet 0,25 mg tablet 106.00 - -
71 Digoksin 0,25 mg Tablet 104.00 - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 - -
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 - -
75 Domperidon tablet 10 mg tablet 86.00 200 1000 1200 200 1000 - -
Page 71
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 10 - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 200 200 - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 - -
83 Eugenol cairan botol 21,091.00 - -
84 Fenobarbital tablet 30 mg tablet 165.00 - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - -
87 tablet 747.00 - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 100 100 100 - -
89 ampul 3,867.00 30 30 30 - -
mg/ml
90 Fituno Tab tablet 4,163.10 - -
91 Furosemid Inj 10 mg/ml ampul 1,333.00 25 25 25 - -
92 Furosemide tablet 40 mg tablet 77.00 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 5 5 5 10 5 5 14,050
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 5 5 5 30 20 20 89,040
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1000 1000 400 600 - -
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 - -
99 Griseofulvin tablet 125 mg tablet 232.00 - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - -
101 Haloperidol 0,5 mg Tablet 55.00 460 40 420 - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 100 100 100 - -
103 Hidrokortison krim 2,5 % tube 2,640.00 24 24 7 17 - -
104 Hidrokortison krim 2,5% tube 2,475.00 - -
Page 72
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
105 Hustab Syrup botol 11,550.00 50 50 50 577,500
106 Hustab P Tablet 8 mg Tablet 256.67 900 900 900 900 900 900 231,003
107 Hustab Tablet tablet 437.00 - -
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 3000 3000 700 2300
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00
selaput
110 Ibuprofen 200 mg Tablet 550.00 - -
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - -
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - -

116 tablet 63.00 300 500 800 600 200 500 500 500 31,500
117 Kanamycin 1 gr inj vial 10,768.00 - -
118 Kaptopril 12,5 mg tablet 68.00 1000 1000 100 900 - -
119 Ketokenazol tablet 200 mg tablet 278.00 - -
120 Ketokonazol tablet 200 mg tablet 297.00 - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - -
123 Kloramfenikol Salep 2% tube 3,349.00 - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 - -
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - -
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - -
129 Klorfeniramin maleat tablet 25.00 2000 2000 2000 3000 3000 3,000 75,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 1000 1000 600 400 500 200 200 60,600
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 100 100 - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 500 500 100 400 - -
134 Meloksikam 7,5 mg tablet 795.68 - -
Page 73
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
135 Meloxicam tab15 mg tablet 1,438.80 500 500 500 1000 800 800 1,151,040
136 Meloxicam 15 mg Tablet 980.00 - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 - -
138 tablet 137.00 500 500 500 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - -
140 Methylprednisolone tablet 4 mg tablet 528.66 - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 500 500 - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - -
146 Metronidazole tablet 500 mg tablet 264.00 700 700 500 200 500 500 500 132,000
147 MgSO4 20 % botol 13,500.00 - -
148 MgSO4 40 % botol 13,500.00 - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 48 48 38 10 48 48 48 172,080
150 NaCl 0,9 % 500 ml botol 6,840.00 40 40 26 14 - -
151 tablet 132.00 200 200 - -
25 mg
152 tablet 127.00 150 500 750 750 1000 - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 1000 1000 400 600 500 - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - -
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 10 - -
161 Omeprazol Tab Tablet 650.00 200 200 200 1000 400 400 260,000
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - -
163 Paracetamol Tab 500 mg tablet 290.00 - -
Page 74
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
164 Paracetamol kaplet 500 mg kaplet 165.00 2000 2000 2000 2000 2000 2,000 330,000
165 bottle 6,981.00 - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 20 20 20 50 - -
167 Pehacain Injeksi ampul 3,113.06 40 40 40 60 - -
168 Pehacain Injeksi Ampul 3,113.05 60 60 60 186,783
169 Pehamoksil Tablet 500 mg Tablet 759.00 - -
170 Pehastan 500 mg tablet 445.50 2000 2000 2000 2500 2500 2,500 1,113,750
171 Pehavral tablet 935.00 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 - -
173 Peridol Syrup 60 ml botol 19,800.00 10 24 34 34 50 - -
174 botol 124,355.00 - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 50 50 50 - -
176 tablet 302.00 - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 100 100 100 - -
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - -
179 Pirantel Pamoat syrup botol 10,778.00 - -
180 Tablet 124.00 300 300 300 - -
(HCl)
181 tablet 129.00 - -
(HCl)
182 Prednison tablet 5 mg tablet 76.00 1000 1000 1000 - -
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 200 200 - -
185 Pyridol Syrup 60 ml botol 18,150.00 - -
186 Ranitidin 150 mg Tablet tablet 660.00 1000 1000 1000 2000 1000 1,000 660,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 - -
189 Retinol/ Vit A 100.000 UI capsule 304.00 - -
190 Retinol/ Vit A 200.000 UI capsule 543.99 20 20 20 - -
191 Ringer Laktat 500 ml botol 7,630.00 14 20 34 34 60 - -
192 Roeko Endo Frost 200 ml botol 352,000.00 - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - -
194 Salbutamol 2 mg tab tablet 67.00 - -
Page 75
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1000 1000 700 300 500 500 500 40,000
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - -
198 pot 2,654.00 - -
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - -
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 240 600 840 600 240 510 510 510 59,670
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 5 1 4 - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 5 5 - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 100 100 - -
208 tablet 84.00 - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 400 400 - -
tablet
210 salut 93.00 300 300 300 - -
selaput
211 Vapril 25 mg tablet 193.00 2000 2000 600 1400 - -
212 box 6,550.00 - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 2000 2000 1300 700 800 800 800 98,400
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 200 200 200 200 100 100 113,600
215 Vitamin B12 tablet 50 mcg tablet 52.00 100 1000 1100 700 400 500 500 500 26,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - -
217 Vitamin B6 10 mg tablet 138.00 - -
218 9,646.00 - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - -
OBAT GIZI (DAK 2019)
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 16800 16800 18600 - -
221 Hemafort tablet 834.90 500 500 500 417,450
Page 76
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - -
224 Kapsul 581.00 - -
IU
BAHAN MEDIS HABIS PAKAI (DAK )
225 Allkohol 70% bottle 28,733.33 1 1 - -
226 Alkohol 70% 1L botol 28,750.00 - -
227 Arm sling L buah 17,424.00 - -
228 Arm sling M buah 17,424.00 - -
229 Arm sling S buah 17,424.00 - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 5 5 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 - -
232 Aximed Syringe 1 cc Dus 103,750.00 - -
233 Aximed Syringe 3 cc Dus 103,125.00 1 1 1 103,125
234 Blood Lancet box 16,022.60 - -
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 24 24 - -
237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 - -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 12 12 12 417,240
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - -
Page 77
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
251 Chirurgic Gloves, size 7 pcs 9,525.12 - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - -
255 Dermafix T 10x12cm pcs 6,939.90 - -
256 Examination Gloves size L box 58,564.00 5 5 5 292,820
257 Examination Gloves size M box 58,564.00 5 5 5 292,820
258 Examination Gloves size S box 58,564.00 - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - -
267 Hb Sahli set 96,800.00 - -
268 Hidrogen Peroxide 3% botol 3,864.00 - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - -
270 Infuset pcs 6,166.16 - -
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - -
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 50 50 50 404,443
275 Kapas pembalut 250 gr roll 13,733.33 - -
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 90 90 - -
Page 78
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 15 15 - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 50 50 - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - -
282 Lysol 1 liter botol 47,150.00 - -
283 Masker Ear Loop Box 20,202.00 - -
284 Masker Tie on Box 19,869.00 - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - -
289 Onemed Alcohol Swab botol 11,000.00 - -
290 Onemed Blood Lancet box 16,022.60 - -
291 Onesept 500 ml botol 30,360.00 - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - -
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - -
295 Safeglove Examination Gloves L box 39,182.00 - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - -
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - -
300 Stera Infuset anak pcs 3,850.00 - -
301 Surgical Mask Earloop box 18,150.00 5 5 5 20 9 9 163,350
302 Surgical Mask Tie On box 18,150.00 1 1 1 18,150
303 Swab 2 ply dus 14,040.84 - -
304 Syringe 10 cc dus 167,266.70 - -
305 Syringe 1cc pcs 1,045.80 - -
306 Syringe 1cc dus 106,523.56 - -
307 Syringe 3cc dus 107,421.38 - -
308 Syringe 5cc dus 119,090.61 - -
Page 79
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - -
312 Tp. Disposable Syringe 5 cc pcs 892.78 - -

313 pcs 7,072.50 - -
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - -
318 Urine bag steril (t-valve) pcs 3,300.00 - -
PEMERIKSAAN HIV
319 HIV Device Box 707,143.00 12 12 12 - -
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - -
SUMBER DANA APBD I
VAKSIN
321 BCG +Pelarut BCG Vial 61,996.00 - -
322 Campak + Pelarut Campak Vial 28,204.00 - -
323 DPT-HB-Hib Vial 78,991.00 - -
324 DT Vial 17,996.00 - -
325 Hepatits B Buah 23,991.00 - -
326 IPV Vial 139,760.00 - -
327 IPV Vial 144,540.00 - -
328 MR Vial 141,648.00 - -
329 Polio+ Dropper Polio Vial 19,954.00 - -
330 Td Vial 16,995.00 - -
ANTI RABIES
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - -
OBAT FILARIASIS
Page 80
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
332 Albendazol 400 mg tablet 258.74 - -
OBAT GIZI
333 Tablet Tambah Darah (Rematri) tablet 372.00 - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - -
OBAT MALARIA
336 Blood Slide Kotak 18,509.00 5 5 5 - -
337 DHP Frimal tablet 3,498.00 - -
338 Kelambu GF Buah 61,077.00 - -
339 Primaquin 15 mg tablet 235.00 100 100 100 - -
OBAT KIA IBU
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 10 10 - -
341 Ca. Glukonas Injeksi ampul 10,351.00 3 3 - -
342 Euthyrox 50 mcg tablet 735.00 - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 20 20 - -
344 Methylergometrin Injeksi ampul 3,102.00 50 10 - -
345 MgSO4 20 % fls 3,328.00 12 12 - -
346 MgSO4 40 % fls 3,796.00 12 12 - -
OBAT KIA ANAK
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - -
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 - -
OBAT TB PARU
350 Box Slide Kotak 41,342.00 - -
351 Kaca Slide Kotak 30,000.00 - -
353 OAT Kategori Anak Paket 232,518.00 - -
354 OAT Kategori I Paket 377,900.00 - -
355 OAT Kategori II Paket 1,259,990.00 - -
356 Pot Sputum Pot 2,500.00 1000 1000 1000 - -
Page 81
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
357 Reagen Ziehl Neelsen Kit 276,000.00 14 14 14 - -
358 Sputum Pot Buah 2,950.00 - -
359 Tuberkulin Vial 625,900.00 - -
KUSTA
360 MDT PB Dewasa Blister 12,569.00 - -
ALAT DETEKSI RESIKO KEHAMILAN
361 Paket ADRK II Paket 422,980.00 - -
IMUNISASI
362 ADS 0,05 ml Buah 1,518.00 - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - -
364 ADS 0,5 ml Buah 1,127.00 - -
365 ADS 0,5 ml Buah 1,090.00 - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - -
369 ADS 5 ml buah 1,705.00 - -
370 ADS 5 ml Buah 1,705.00 - -
371 ADS 5 ml Buah 1,439.00 - -
372 ADS 5 ml Buah 1,500.00 - -
373 RCW Unit 2,266,454.00 - -
374 Safety Box pcs 16,608.00 - -
375 Safety Box 2,5 ml Buah 12,500.00 - -
376 Safety Box 5 ml Buah 20,394.00 - -
377 Vaccine Carrier buah 1,870,000.00 - -
OBAT FLU BURUNG
378 Oseltamivir kapsul 12,969.00 - -
OBAT DIARE
379 Garam Oralit Sachet 257.00 - -
381 Zink Tablet tablet 551.00 500 500 500 - -
Page 82
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT HIV/AIDS
382 Rapid 1 : SD HIV test 11,975.00 - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - -
384 Rapid Sifilis Ab test 20,400.00 - -
385 RPR Sifilis test 4,250.00 - -
OBAT HEPATITIS
386 HB Imuno Globulin Kotak 1,325,000.00 - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - -
Reagensia/ Alat
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 400 400 400 - -
389 Rapid 2 HIV (Focus) test 13,615.00 - -
390 Rapid 2 HIV (KHB) test 12,500.00 - -
391 Rapid 3 Diagnostar test 13,771.00 - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - -
393 Rapid Sifilis Trepocheck test 9,697.00 50 50 50 - -
SUMBER DANA APBD II
OBAT KATARAK
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - -
OBAT PROGRAM
397 L- Zinc botol 31,350.00 - -
398 Lagesil Suspensi botol 40,755.00 - -
REAGENTIA
399 Objek Gelas Kotak 50,000.00 - -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - -
REAGENSIA
401 Larutan Alkohol 96% botol 242,000.00 - -
402 Larutan Metanol botol 665,500.00 - -
403 Reagen Benedict botol 484,000.00 - -
Page 83
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
404 Reagen Natrium Sitrat botol 514,250.00 - -
405 Reagen Receker botol 2,238,500.00 - -
406 Reagensia Asam Asetat botol 544,500.00 - -
407 Slide test widal Unit 302,500.00 - -
BELANJA STICK NARKOBA
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 1 1 1 - -
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - -
PENINGKATAN KESEHATAN MASYARAKAT
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - -
Ringer Laktat/Ringer Lactate 500 ml botol 7,630.000 60 60 60 457,800
Lysol 1 liter botol 82,150.00 20 20 20 1,643,000
TOTAL 13,360,910

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Hj. Hasinah, SKM Nurmiani Naibaho
Page 84
0
0
1000
0
0
2000
0
0
0
0
0
0
0
0
0
0
0
2000
Page 85
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
500
0
0
Page 86
0
0
10
700
480
0
3000
0
0
0
0
0
500
0
0
30
0
0
0
0
0
1000
Page 87
0
0
0
0
0
0
0
0
0
100
30
0
25
0
0
1000
0
0
0
100
24
0
Page 88
0
900
0
3000
0
0
0
0
500
0
1000
0
0
0
0
0
0
0
0
0
0
2000
1000
0
0
500
0
Page 89
500
0
200
500
0
0
0
0
0
0
700
0
0
48
40
500
1000
0
0
0
0
0
0
0
200
0
0
Page 90
2000
20
0
40
0
2000
0
0
24
50
100
0
0
300
1000
0
0
0
1000
0
0
20
0
20
0
0
0
Page 91
1000
0
0
0
0
0
600
0
0
0
300
2000
2000
200
1000
0
0
0
0
16800
0
Page 92
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 93
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 94
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
0
0
0
0
Page 95
0
0
0
0
0
0
0
0
0
0
12
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 96
0
0
0
0
0
0
5
0
0
100
0
0
0
0
0
50
0
0
0
0
0
25
0
0
0
0
0
0
0
1000
Page 97
14
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
500
Page 98
0
0
0
0
0
0
0
0
0
400
0
0
0
0
50
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 99
0
0
0
0
0
1
0
0
0
0
Page 100
DINKES
PUSKESMAS :BATU TUNGGAL LAPORAN TRIWULAN : I (II) III IV GFK 15/IFK/3/2020 24-Sep-20
KECAMATAN :NA IX X PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 - 1,000 - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 1,500 800 2,300 1,500 800 1,000 1,000 1,000 1,050,000
3 Alopurinol tablet 100 mg tablet 97.00 1,560 800 2,360 1,410 950 800 800 800 77,600
5 Ambroxol 15 mg/5 ml botol 6,600.00 88 50 138 - 138 50 50 50 330,000
6 Ambroxol tab 30 mg tablet 330.00 1,800 800 2,600 800 1,800 1,000 1,000 1,000 330,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 90 - 90 - 90 - - -
8 Aminofilin tablet 200 mg tablet 92.00 100 - 100 - 100 - - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 100 - 100 - 100 - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 620 - 620 620 - - - -
11 tablet 78.00 - 900 900 400 500 1,200 1,200 1,200 93,600
12 Kaplet 94.00 - 1,200 1,200 1,200 112,800
13 Amoksisilin 100 mg/mL botol 13,500.00 20 - 20 - 20 - - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 500 - 500 - 500 - - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 10 100 110 10 100 50 50 50 330,000
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 72 120 192 32 160 100 60 60 220,200
17 kaptab 261.00 - 3,100 3,100 - 3,100 5,000 5,000 5,000 1,305,000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 20 - 20 - 20 - - -
19 Antasida Tablet box 5,594.00 - - -
20 Antasida Tablet tablet 200.00 3,400 - 3,400 2,900 500 5,000 - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
21 Antasida Tab Tablet 355.00 - 5,000 5,000 - 5,000 4,000 1,000 1,000 355,000
22 tablet 60.00 - - -
23 botol 2,189.00 12 100 112 43 69 100 100 100 218,900

+ Polimiksin 10.000
3,071.00
IU/g 47 50 97 47 50 50 25 25 76,775

25 pot 4,540.00 48 48 96 4 92 - - -
Asam Salisilat 3%

26 3,325.00 90 100 100 10 85 - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - - - - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 27 - 27 - - - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 - - - - - - - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 6 - 6 - 6 - - -
33 Bedak salisil serbuk 2% dus 1,040.00 66 - 66 66 - - - -
34 Bedak Salisil Kotak 8,000.00 - 30 30 - 30 30 30 30 240,000
35 Betametason krim 0,5 mg/g tube 3,388.00 122 - 122 86 36 80 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - 50 50 50 67,000
37 Ampul 130,999.00 - - - - - 10 2 2 261,998
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - - - 2 1 1 512,204
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 390 60 450 450 - 800 - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 166 - 166 166 ED - 100 - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - - - - 144 144 144 451,872
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 13 - 13 3 10 20 - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
46 Cetirizin Hydrochloride salut 94.00 700 - 700 700 - 1,500 - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - 300 300 - 300 700 700 700 70,700
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 36 100 136 34 102 100 100 100 297,300
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 1,300 - 1,300 - 1,300 - - -
tablet
50 salut 165.00 - 200 200 - 200 - - -
selaput
51 kapsul 770.00 1,400 - 1,400 1,300 100 2,000 2,000 2,000 1,540,000
52 Codeine 10 mg tablet 600.00 1,020 - 1,020 50 970 - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - - - 200 - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 - 100 100 32 68 100 50 50 109,500

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 480 1,000 1,480 300 1,180 1,500 700 700 93,100
56 tablet 47.00 - 200 - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 437 ED 150 150 125 125 240 240 240 276,480
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 2,560 2,000 4,560 1,660 2,900 2,000 - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - -
61 Dekstrofen Syrup Botol 11,550.00 106 - 106 48 58 150 - -
62 Diazepam 2 mg Tablet 86.00 - - - - - 200 200 200 17,200
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 25 - 25 - 25 - - -
65 Diclofenac Sodium 25 mg Tablet 141.00 - 1,500 1,500 1,500 211,500
66 Diclofenac Sodium 50 mg Tablet 136.00 - 5,600 5,600 5,600 761,600
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 179 - 179 179 - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - 150 150 5 145 210 210
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - -
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - - - - -
71 Digoksin 0,25 mg Tablet 104.00 - 300 300 - 300 - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 400 - 400 400ED - 500 - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 36 100 136 - 136 150 - -
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 2,055 - 2,055 1,755 300 2,000 - -
75 Domperidon tablet 10 mg tablet 86.00 - 1,000 1,000 - 1,000 1,000 1,000 1,000 86,000
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - - - - - 50 2 2 11,800
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 - 50 6 6 36,000
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 10 - 10 - 10 - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 600 - 600 - 600 - - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 87 - 87 - 87 50 - -
83 Eugenol cairan botol 21,091.00 5 - 5 - - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 1,390 - 1,390 50 1,340 - - -
85 Fenobarbital tablet 30 mg tablet 180.00 - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 62 24 86 38 48 50 - -
87 tablet 747.00 390 - 390 - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 400 790 170 620 500 500 500 398,500
89 ampul 3,867.00 64 30 94 34 60 60 30 30 116,010
mg/ml
90 Fituno Tab tablet 4,163.10 - 330 330 30 300 1,500 90 90 374,679
91 Furosemid Inj 10 mg/ml ampul 1,333.00 10 - 10 - 10 - - -
92 Furosemide tablet 40 mg tablet 77.00 4,340 - 4,340 4190ED 150 500 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - 24 24 - 24 24 10 10 28,100

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - 24 24 - 24 24 10 10 44,520
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1,430 1,000 2,430 230 2,200 1,000 500 500 62,500
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 40 - 40 - 40 - - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 500 1,570 900 670 1,000 1,000 1,000 245,000
99 Griseofulvin tablet 125 mg tablet 232.00 1,070 - 1,070 - - - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - - - - -
101 Haloperidol 0,5 mg Tablet 55.00 280 - 280 60 220 300 200 200 11,000
102 Hidroklorotiazid tab 25 mg tablet 163.00 - 500 500 - 500 - - -
103 Hidrokortison krim 2,5 % tube 2,640.00 111 48 159 111 48 100 - -
104 Hidrokortison krim 2,5% tube 2,475.00 - 48 48 48 118,800
105 Hustab Syrup botol 11,550.00 - 150 150 - 150 100 50 50 577,500
106 Hustab P Tablet 8 mg Tablet 256.67 600 1,200 1,800 - 1,800 2,500 2,100 2,100 539,007
107 Hustab Tablet tablet 437.00 970 1,200 2,170 670 1,500 3,600 3,600 3,600 1,573,200
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 -
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 3,250 - 3,250 2,750 500 2,000
selaput
110 Ibuprofen 200 mg Tablet 550.00 - 700 700 - 700 500 500 500 275,000
111 Ibuprofen 400 mg Tablet 800.00 - 700 700 - 700 2,000 500 500 400,000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 89 - 89 31 58 100 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - 50 50 - 50 100 100 100 277,600
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 400 - 400 - 400 - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 1,300 - 1,300 1,150 150 2,000 - -
116 tablet 63.00 - 2,000 2,000 - 2,000 2,500 1,500 1,500 94,500
117 Kanamycin 1 gr inj vial 10,768.00 - - - - - 20 - -
118 Kaptopril 12,5 mg tablet 68.00 500 1,200 1,700 - 1,700 1,500 1,000 1,000 68,000
119 Ketokenazol tablet 200 mg tablet 278.00 100 - 100 100 - 1,000 - -
120 Ketokonazol tablet 200 mg tablet 297.00 200 200 - 200 1,000 - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
121 Kloramfenicol kapsul 250 mg Capsule 320.00 - - -

122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - 600 600 600 396,000
123 Kloramfenikol Salep 2% tube 3,349.00 - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 157 24 181 133 48 50 24 24 48,168
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 71 - 71 71 - 50 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - 100 100 100 516,800
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 8,040 - 8,040 8,040 - 10,000 - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - -
129 Klorfeniramin maleat tablet 25.00 - 19,600 19,600 19,600 490,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 1,360 1,360 - 1,360 2,500 200 200 60,600
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 - - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 122 - 122 122 - 100 - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 - 700 700 - 700 2,000 1,000 1,000 260,000
134 Meloksikam 7,5 mg tablet 795.68 - - -
135 Meloxicam tab15 mg tablet 1,438.80 1,640 800 2,440 1,440 1,000 1,500 1,000 1,000 1,438,800
136 Meloxicam 15 mg Tablet 980.00 - - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 280 300 580 80 500 1,800 - -
138 tablet 137.00 2,300 1,300 3,600 2,400 1,200 2,000 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - 1,500 1,500 1,500 219,000
140 Methylprednisolone tablet 4 mg tablet 528.66 - - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 1,000 - 1,000 - 1,000 - - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 500 1,000 1,500 200 1,300 1,500 1,000 1,000 80,000
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - 50 50 - 50 - -
146 Metronidazole tablet 500 mg tablet 264.00 1,530 1,000 1,530 330 1,200 1,500 700 700 184,800
147 MgSO4 20 % botol 13,500.00 - - - - 20 - -
148 MgSO4 40 % botol 13,500.00 - - - - 10 - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
150 NaCl 0,9 % 500 ml botol 6,840.00 87 - 87 10 77 60 40 40 273,600
151 tablet 132.00 1,250 1,000 2,250 1,550 700 1,500 - -
25 mg
152 tablet 127.00 3,550 3,350 6,950 3,600 3,350 - - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 800 - 800 200 600 300 - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 100 - 100 100 - - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - 200 200 - 200 1,000 200 200 177,200
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 4 - 4 4 - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 48 - 48 33 15 30 - -
161 Omeprazol Tab Tablet 650.00 2,470 200 2,670 2,470 200 3,000 400 400 260,000
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - -
163 Paracetamol Tab 500 mg tablet 290.00 - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 1,180 5,200 6,380 1,080 5,300 5,200 5,200 5,200 858,000
165 bottle 6,981.00 37 - 37 37 - 100 - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - 50 50 12 38 150 - -
167 Pehacain Injeksi ampul 3,113.06 - - -
168 Pehacain Injeksi Ampul 3,113.05 702 100 802 679 ED 123 - - -
169 Pehamoksil Tablet 500 mg Tablet 759.00 2,100 - 2,100 2,100 - 5,000 - -
170 Pehastan 500 mg tablet 445.50 - 3,600 3,600 300 3,300 1,500 1,500 1,500 668,250
171 Pehavral tablet 935.00 - 2,000 2,000 - 2,000 2,000 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 47 - 47 47 - 30 - -
173 Peridol Syrup 60 ml botol 19,800.00 24 - -
174 botol 124,355.00 4 - 4 - 4 - - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 100 - 100 - 100 100 100 100 88,000
176 tablet 302.00 200 100 300 200 100 500 - -
mg
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
177 Pirantel pamoat 125 mg tab tablet 322.00 - - -

178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 22 - 22 22 - 30 - -
179 Pirantel Pamoat syrup botol 10,778.00 - - -
180 Tablet 124.00 - - - - - - - -
(HCl)
181 tablet 129.00 1,200 - 1,200 700 500 1,000 1,000 1,000 129,000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 1,700 - 1,700 1,300 1,000 1,000 1,000 76,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 400 1,000 - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 2,680 - 2,680 1,990 690 1,000 300 300 42,600
185 Pyridol Syrup 60 ml botol 18,150.00 88 - 88 88 - 100 - -
186 Ranitidin 150 mg Tablet tablet 660.00 3,300 - 3,300 3,300 - 3,000 900 900 594,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 45 200 245 88 157 250 200 200 231,000
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - -
191 Ringer Laktat 500 ml botol 7,630.00 151 - 151 20 131 40 - -
192 Roeko Endo Frost 200 ml botol 352,000.00 - - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 1,390 - 1,390 990 400 - - -
194 Salbutamol 2 mg tab tablet 67.00 - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 2,700 - 2,700 300 2,400 - - -
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - - - 10 - -
198 pot 2,654.00 27 72 99 64 48 50 48 48 127,392
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 1,010 800 1,810 1,010 800 1,000 1,000 1,000 1,210,000
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - 20 20 - 20 20 20 20 99,960
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 93 - 93 35 64 - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 3,180 - 3,180 1,190 1,990 - - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 - - -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 - - - - - - - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - 5 5 5 66,010
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - 5 5 5 95,965
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 930 - 930 70 860 - - -
208 tablet 84.00 1,680 - 1,680 880 800 - - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - - -
tablet
210 salut 93.00 - 200 200 - 200 - - -
selaput
211 Vapril 25 mg tablet 193.00 1,900 - 1,900 400 1,500 - - -
212 box 6,550.00 - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,910 1,000 2,910 2,410 500 3,000 1,000 1,000 123,000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 - 300 300 30 270 500 200 200 227,200
215 Vitamin B12 tablet 50 mcg tablet 52.00 1,000 1,000 1,000 52,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 2,200 1,000 3,200 - 3,200 - - -
217 Vitamin B6 10 mg tablet 138.00 - - -
218 9,646.00 20 - 20 - 20 - - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 170 - 170 40 130 - - -
OBAT GIZI (DAK 2019) -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 5400 ed 16,800 16,800 500 16,300 - -
221 Hemafort tablet 834.90 1,300 1,500 2,800 1,800 1,000 2,200 2,200 2,200 1,836,780
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - -
224 Kapsul 581.00 - - -
IU
225 Allkohol 70% bottle 28,733.33 - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
226 Alkohol 70% 1L botol 28,750.00 17 - 17 5 10 - -
227 Arm sling L buah 17,424.00 5 - 5 - 5 - - -
228 Arm sling M buah 17,424.00 5 - 5 - 5 - - -
229 Arm sling S buah 17,424.00 5 - 5 - 5 - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 24 - 24 24 - 30 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 38 - 38 38ED - - - -
232 Aximed Syringe 1 cc Dus 103,750.00 2 2 - 2 - -
233 Aximed Syringe 3 cc Dus 103,125.00 - 10 10 5 5 10 10 10 1,031,250
234 Blood Lancet box 16,022.60 2 - 2 - 2 - - -
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 48 - 48 20 28 - - -
237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 - - -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 37 - 37 13 24 - - -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - 24 - -
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - - -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 43 - 43 23 20 - - -
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 24 - 24 24 - 24 24 24 992,760
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - -
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
253 Chirurgic Gloves, size 8 pcs 9,525.12 - - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 60 10 70 30 40 20 20 20 103,960
255 Dermafix T 10x12cm pcs 6,939.90 30 10 40 - 30 20 20 20 138,798
256 Examination Gloves size L box 58,564.00 - - -
257 Examination Gloves size M box 58,564.00 - - -
258 Examination Gloves size S box 58,564.00 - - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 10 - 10 5 5 - - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 10 - 10 - 10 - - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - -
263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 - - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - - -
267 Hb Sahli set 96,800.00 - -
268 Hidrogen Peroxide 3% botol 3,864.00 2 1 3 2 1 - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - 15 - -
270 Infuset pcs 6,166.16 - 50 50 50 308,308
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - -
276 Kapas pembalut 250 gr roll 13,750.00 18 - 18 5 13 - - -
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 13 13 - 13 24 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 - 100 100 - 100 100 100 100 176,000
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - - - - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 27 - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 11 10 21 16 5 10 10 10 81,224
282 Lysol 1 liter botol 47,150.00 - 5 5 - 5 5 - -
283 Masker Ear Loop Box 20,202.00 - 3 - -
284 Masker Tie on Box 19,869.00 3 - 3 3 - 3 - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - -
289 Onemed Alcohol Swab botol 11,000.00 2 2 2 - 2 - - -
290 Onemed Blood Lancet box 16,022.60 - - -
291 Onesept 500 ml botol 30,360.00 - - - - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 6 - 10 4 - - - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 3 2 2 2 13,700
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 10 - 10 - 10 - - -
295 Safeglove Examination Gloves L box 39,182.00 3 - 3 - - - - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - - -
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - -
300 Stera Infuset anak pcs 3,850.00 90 - 90 90 - - - -
301 Surgical Mask Earloop box 18,150.00 - - -
302 Surgical Mask Tie On box 18,150.00 - 8 8 - 8 - -
303 Swab 2 ply dus 14,040.84 - - -
304 Syringe 10 cc dus 167,266.70 - 1 1 - 1 1 - -
305 Syringe 1cc pcs 1,045.80 300 300 100 200 - -
306 Syringe 1cc dus 106,523.56 - - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
307 Syringe 3cc dus 107,421.38 - - -
308 Syringe 5cc dus 119,090.61 - 1 1 - 1 1 1 1 119,091
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - - -

313 pcs 7,072.50 - - -
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - -
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 - - -
318 Urine bag steril (t-valve) pcs 3,300.00 10 - 10 - 10 - - -
PEMERIKSAAN HIV
319 HIV Device Box 707,143.00 12 1 - -
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 40 - 40 28 20 - - -
SUMBER DANA APBD I -
VAKSIN -
322 Campak + Pelarut Campak Vial 28,204.00 - - -
323 DPT-HB-Hib Vial 78,991.00 - - -
324 DT Vial 17,996.00 - - -
325 Hepatits B Buah 23,991.00 - -
326 IPV Vial 139,760.00 - - -
327 IPV Vial 144,540.00 - -
328 MR Vial 141,648.00 - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
330 Td Vial 16,995.00 - -
ANTI RABIES
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - 3 - -
OBAT FILARIASIS
332 Albendazol 400 mg tablet 258.74 5200 ed - 5,200 - - 1,500 - -
OBAT GIZI
333 Tablet Tambah Darah (Rematri) tablet 372.00 - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - -
OBAT MALARIA
336 Blood Slide Kotak 18,509.00 - -
338 Kelambu GF Buah 61,077.00 - -
339 Primaquin 15 mg tablet 235.00 - -
OBAT KIA IBU
341 Ca. Glukonas Injeksi ampul 10,351.00 - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - -
344 Methylergometrin Injeksi ampul 3,102.00 - -
345 MgSO4 20 % fls 3,328.00 - -
346 MgSO4 40 % fls 3,796.00 - -
OBAT KIA ANAK
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - -
OBAT TB PARU
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
350 Box Slide Kotak 41,342.00 - -
356 Pot Sputum Pot 2,500.00 1,000 - -
357 Reagen Ziehl Neelsen Kit 276,000.00 15 - -
KUSTA
IMUNISASI
362 ADS 0,05 ml Buah 1,518.00 - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - -
364 ADS 0,5 ml Buah 1,127.00 - -
365 ADS 0,5 ml Buah 1,090.00 - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - -
369 ADS 5 ml buah 1,705.00 - -
370 ADS 5 ml Buah 1,705.00 - -
371 ADS 5 ml Buah 1,439.00 - -
372 ADS 5 ml Buah 1,500.00 - -
373 RCW Unit 2,266,454.00 - -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
374 Safety Box pcs 16,608.00 - - - - - - -
OBAT FLU BURUNG
OBAT DIARE
381 Zink Tablet tablet 551.00 - -
OBAT HIV/AIDS
382 Rapid 1 : SD HIV test 11,975.00 300 - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - -
OBAT HEPATITIS
Reagensia/ Alat
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - -
393 Rapid Sifilis Trepocheck test 9,697.00 100 - -
SUMBER DANA APBD II

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT KATARAK
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 18 - 18 - 18 50 - -
OBAT PROGRAM
397 L- Zinc botol 31,350.00 22 5 27 22 5 40 - -
398 Lagesil Suspensi botol 40,755.00 30 20 50 30 20 40 - -
REAGENTIA
REAGENSIA
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 2 - -

Ringer Laktat 500 ml botol 40 40 40 -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Masker box 450,000.00 10 10 10 4,500,000
botol 84,866.00 5 5 5 424,330

Handrub 500 ml
TOTAL 42,013,721

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr. Yudha Jusliansyah Sitorus Ratna Maimunah
10 D KARTU
DINKES
PUSKESMAS : Simonis LAPORAN TRIWULAN : I (II) III IV GFK 14/IFK/3/2020 9/23/2020
KECAMATAN : Aek Natas PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
KABUPATEN : Labuhanbatu Utara
PROVINSI : Sumatera Utara
JUMLAH PEMBERIAN
HARGA SATUAN STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT
NO NAMA OBAT SATUAN TOTAL
(Rp) AWAL AAN AAN AN STOK OPT AAN DAK APBDI APBD II TOTAL HARGA KET
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
1 Acetyl cysteine/ N-Asetil sistein tablet/kaplet/kapsul 200 mg capsule 357.00 - - 1000 - -

2 Acyclovir 200 mg Tablet 1,050.00 - - - -
3 Alopurinol tablet 100 mg tablet 97.00 2400 1000 3,400 2,800 600 2000 2000 2,000 194,000.00
5 Ambroxol 15 mg/5 ml botol 6,600.00 51 100 151 106 45 200 200 200 1,320,000.00
6 Ambroxol tab 30 mg tablet 330.00 1000 1000 2,000 1,700 300 2500 2500 2,500 825,000.00
7 Aminofilin inj 24 mg/ml ampul 2,998.00 - - - -
8 Aminofilin tablet 200 mg tablet 92.00 - - 100 100 - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 200 200 150 50 500 - -
11
tablet 78.00 600 600 600 1200 1200 1,200 93,600.00
Amlodipin/Amlodipine/Amlodipine Besilate tablet/kapsul/kaplet

12
10 mg
Kaplet 94.00 - - 300 300 300 28,200.00

14 Amoksisilin 250 mg kapsul Kapsul 203.00 800 700 1,500 1,500 1000 1000 1,000 203,000.00
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 5 100 105 98 7 150 100 100 660,000.00
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 68 60 128 70 58 150 60 60 220,200.00
Amoksisilin/Amoxicillin tablet/kapsul/kaplet/kaptab 500 mg,
17
kemasan strip/blister (G)
kaptab 261.00 2400 3000 5,400 5,000 400 5000 5000 5,000 1,305,000.00

20 Antasida Tablet tablet 200.00 1700 1,700 1,700 5000 - -
21 Antasida Tab Tablet 355.00 4500 4,500 2,300 2200 5000 5000 5,000 1,775,000.00
Antasida tab kunyah, kombinasi: Aluminium Hidroksida 200
22
mg + Magnesium Hidroksida 200 mg
tablet 60.00 - - - -
Antasida suspensi, kombinasi: Aluminium Hidroksida 200 mg +
23
Magnesium Hidroksida 200 mg
botol 2,189.00 34 100 134 79 55 150 100 100 218,900.00
24 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g + Polimiksin

tube 10.000 IU/g 3,071.00 50 50 50 50 25 25 76,775.00
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Antifungi DOEN Salep, Kombinasi: Asam Benzoat 6% + Asam
25
Salisilat 3%
pot 4,540.00 48 48 48 50 24 24 108,960.00
suppositori
26 Antihemoroid, Kombinasi sup: bismut subgalat heksaklorofen
a
3,325.00 - - - -
27 Arkine 100 tablet 687.50 - - - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - - - -
33 Bedak salisil serbuk 2% dus 1,040.00 - - - -
34 Bedak Salisil Kotak 8,000.00 - - - -
35 Betametason krim 0,5 mg/g tube 3,388.00 - - - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - - -
37 Biosat 1,5 Serum antitetanus (A.T.S) inj 1500 IU/amp (i.m) Ampul 130,999.00 1 1 1 - -
kaptab
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 - - - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 42 48 90 90 96 96 96 301,248.00
43 Cefotaxime sodium 1 gr vial 7,342.50 - - 10 - -
tablet salut
46 Cetirizin Hydrochloride
selaput
94.00 - - - -
47 Cetirizine tablet 10 mg tablet 101.00 500 500 500 2000 500 500 50,500.00
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 26 100 126 84 42 100 100 100 297,300.00
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - -
Chlorpromazine hydrochloride/ Chlorpromazine /Klorpromazin tablet salut
50
tablet/kaplet salut selaput 100 mg selaput
165.00 100 100 100 100 100 100 16,500.00

51
kapsul 770.00 300 700 1,000 1,000 1000 1000 1,000 770,000.00
52 Codeine 10 mg tablet 600.00 - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 58 50 108 83 25 100 100 100 219,000.00
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 mg tablet 133.00 600 500 1,100 1,100 1000 500 500 66,500.00
(tab/kaptab 480 mg)
Cyanocobalamin/cyanocobalamine/sianokbalamin(Vit B12)
56
tab/kaps/kapl/ 50 mg
tablet 47.00 - - - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Deksametason sodium
57
phosphate/Dexamethasone/Deksametason injeksi 5 mg/ml
ampul 1,152.00 115 100 215 215 240 240 240 276,480.00
58 Dexamethason inj Ampul 4,500.00 - - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 1900 5000 6,900 5,500 1400 5000 - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - -
62 Diazepam 2 mg Tablet 86.00 100 100 100 - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 100 100 100 - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 20 20 20 - -
65 Diclofenac Sodium 25 mg Tablet 141.00 600 600 600 600 - -
66 Diclofenac Sodium 50 mg Tablet 136.00 2800 2,800 2,800 5600 5600 5,600 761,600.00
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 200 200 200 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - - 90 90 90 103,590.00
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - -
71 Digoksin 0,25 mg Tablet 104.00 300 500 800 700 100 500 500 500 52,000.00
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 400 400 400 - -
Botol
73 Domperidon Suspensi 5 mg/5 ml
Plastik
2,781.00 - 100 100 100 278,100.00
75 Domperidon tablet 10 mg tablet 86.00 800 1500 2,300 2,300 2000 1000 1,000 86,000.00
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - 5 - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 - - - -
selaput
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 - - - -
83 Eugenol cairan botol 21,091.00 2 2 2 - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - 48 - -
Fitomenadion/Phytomenadion (Vit K) tablet/kaplet salut gula
87
10 mg
tablet 747.00 200 200 200 500 - -
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 500 300 800 700 100 300 300 300 239,100.00
89 Fitomenadion / Phytomenadion (Vitamin k1) injeksi 2 mg/ml ampul 3,867.00 79 79 79 - -
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - -
92 Furosemide tablet 40 mg tablet 77.00 480 480 80 400 500 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 5 5 5 5 5 5 14,050.00
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 5 5 5 5 5 5 22,260.00
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 500 500 1,000 1,000 500 500 500 62,500.00
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 - - - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 400 500 900 800 100 500 500 500 122,500.00
101 Haloperidol 0,5 mg Tablet 55.00 70 200 270 10 260 - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 100 100 100 100 100 100 16,300.00
103 Hidrokortison krim 2,5 % tube 2,640.00 48 48 48 48 24 24 63,360.00
104 Hidrokortison krim 2,5% tube 2,475.00 - - - -
105 Hustab Syrup botol 11,550.00 58 50 108 65 43 100 100 100 1,155,000.00
106 Hustab P Tablet 8 mg Tablet 256.67 600 600 1,200 1,200 1200 1200 1,200 308,004.00
107 Hustab Tablet tablet 437.00 - - 3600 3600 3,600 1,573,200.00
tablet salut
108 Ibuprofen tab/kaps/kapl 200 mg
selaput
108.00 - - - -
tablet salut
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg
selaput
105.00 1500 1,500 1,500 3000 - -
110 Ibuprofen 200 mg Tablet 550.00 1000 1,000 1,000 1000 500 500 275,000.00
111 Ibuprofen 400 mg Tablet 800.00 - - - -
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 50 100 150 49 101 100 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - 100 100 100 277,600.00
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - -
Kalsium Laktat/ Calcium lactate (Kalk) tablet/kapsul/kaplet 500
116
mg
tablet 63.00 1200 1000 2,200 1,600 600 2000 2000 2,000 126,000.00
118 Kaptopril 12,5 mg tablet 68.00 400 1000 1,400 1,200 200 1000 1000 1,000 68,000.00
119 Ketokenazol tablet 200 mg tablet 278.00 - - 100 100 - -
120 Ketokonazol tablet 200 mg tablet 297.00 200 200 200 500 - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 480 480 180 300 500 - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 300 300 300 600 600 600 396,000.00
124 Kloramfenikol salep mata 1 % Tube 2,007.00 32 24 56 37 19 48 24 24 48,168.00
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml
Plastik
4,843.00 26 26 - 12 38 50 - -
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 50 50 50 50 50 50 258,400.00
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 2600 2,600 1,700 900 4000 - -
129 Klorfeniramin maleat tablet 25.00 4000 4,000 4,000 4000 4000 4,000 100,000.00
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 500 500 500 0 500 500 500 151,500.00
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 140 140 140 700 - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 - - - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 200 200 100 100 1000 200 200 52,000.00
134 Meloksikam 7,5 mg tablet 795.68 350 500 850 800 50 1000 - -
135 Meloxicam tab15 mg tablet 1,438.80 - 1000 500 500 719,400.00
136 Meloxicam 15 mg Tablet 980.00 - - - -
Metformin Hydrochloride/ Metformin tablet salut
137
tablet/kapsul/kaplet/kaptab 500 mg, kemasan strip/blister (G) selaput
106.00 100 300 400 400 500 - -
138 Metilprednisolon/methylprednisolone tab/kaps/kapl 4 mg tablet 137.00 1300 1500 2,800 2,800 3000 - -
139 Metilprednisolon tablet 4 mg tablet 146.00 - - 3000 3000 3,000 438,000.00
140 Methylprednisolone tablet 4 mg tablet 528.66 - - 1,800 1800 - -
tablet salut
142 Metil Ergometrin tablet Salut Selaput 0,125 mg
selaput
222.00 - - - -
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - 500 500 - -

144
(hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 mg
tablet 80.00 - - - -
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 40 40 40 50 50 50 197,500.00
146 Metronidazole tablet 500 mg tablet 264.00 400 700 1,100 1,100 2000 700 700 184,800.00
147 MgSO4 20 % botol 13,500.00 3 3 3 - -
148 MgSO4 40 % botol 13,500.00 3 3 3 - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 9 48 57 57 48 24 24 86,040.00
150 NaCl 0,9 % 500 ml botol 6,840.00 14 20 34 34 20 20 20 136,800.00
151 Natrium Diklofenak tablet/kapsul/kaplet salit enterik 25 mg tablet 132.00 650 650 600 50 1000 - -
152 Natrium Diklofenak tablet/kapsul/kaplet salit enterik 50 mg tablet 127.00 1350 1,350 1,000 350 1000 - -
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 370 500 870 770 100 500 - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 500 500 500 500 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 300 300 300 300 200 200 177,200.00
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - -
161 Omeprazol Tab Tablet 650.00 200 200 130 70 1000 200 200 130,000.00
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 18 18 18 50 - -
163 Paracetamol Tab 500 mg tablet 290.00 - - 1,200 1200 - -
164 Paracetamol kaplet 500 mg kaplet 165.00 800 4000 4,800 4,800 5200 5200 5,200 858,000.00
Paracetamol/parasetamol drops 100 mg/ml btl @15 ml (60
165
ml/0,6 ml) (G)
bottle 6,981.00 - - - -
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml bottle 1,184.00 20 20 - 1 21 200 - -
167 Pehacain Injeksi ampul 3,113.06 - - - -
168 Pehacain Injeksi Ampul 3,113.05 600 600 600 600 600 600 1,867,830.00
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - 2000 - -
170 Pehastan 500 mg tablet 445.50 300 3000 3,300 3,300 5000 2000 2,000 891,000.00
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
171 Pehavral tablet 935.00 400 1000 1,400 800 600 1000 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 15 15 15 15 - -
173 Peridol Syrup 60 ml botol 19,800.00 24 24 24 24 - -
174 Perio Kin Spray Chlorhexidin Gluconat/ Klorheksidin 0,2 % botol 124,355.00 5 5 5 5 5 5 621,775.00
175 Phaproxin 500 mg tablet 880.00 300 300 50 250 300 300 300 264,000.00
176 Pirantel pamoat / pyrantel pamoate tab/kaps/kapl 125 mg tablet 302.00 - - 52 52 - -
177 Pirantel pamoat 125 mg tab tablet 322.00 100 100 200 200 200 200 200 64,400.00
180 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 124.00 - - 600 600 - -
181 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) tablet 129.00 300 2000 2,300 2,300 2000 2000 2,000 258,000.00
182 Prednison tablet 5 mg tablet 76.00 1400 2000 3,400 3,200 200 2000 1500 1,500 114,000.00
184 Pularex Attapulgit tab 630 mg tablet 142.00 300 300 600 600 300 100 100 14,200.00
185 Pyridol Syrup 60 ml botol 18,150.00 - - 0 50 - -
186 Ranitidin 150 mg Tablet tablet 660.00 1000 1,000 1,000 0 5000 1000 1,000 660,000.00
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - 200 - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 150 150 150 200 200 200 231,000.00
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - 100 - -
190 Retinol/ Vit A 200.000 UI capsule 543.99 - - 100 - -
191 Ringer Laktat 500 ml botol 7,630.00 104 100 204 204 100 100 100 763,000.00
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - - - -
194 Salbutamol 2 mg tab tablet 67.00 - - 200 200 - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 300 500 800 800 1000 1000 1,000 80,000.00
198 Salep 2-4, kombinasi: asam salisilat 2% + belerang endap 4% pot 2,654.00 48 48 48 96 96 96 254,784.00
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - - - -
200 Seftriakson serb inj 1.000 mg vial 4,998.00 10 10 10 - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 26 26 26 50 - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - - 340 340 - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 300 1680 1,980 1,980 3360 3360 3,360 393,120.00
tablet salut
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg
selaput
214.00 - - - -
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - - -

206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 300 300 200 100 500 - -
208 Tiamin (Vitamin B1) Tablet/Kapsul/kaplet 50 mg (HCL/Nitrat) tablet 84.00 800 800 500 300 1000 - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 1000 1,000 1,000 1000 500 500 43,000.00
Trihexyphenidyl hydrochloride (HCl)/ Triheksifenidil tablet salut
210
tablet/kapsul/kaplet 2 mg selaput
93.00 130 300 430 70 360 - -
211 Vapril 25 mg tablet 193.00 1000 1,000 800 200 1000 - -

212 Ventolin Rotahaler (Alat Hirup Salbutamol 200 mcg/kapsul) box 6,550.00 - - - -
213 Vitamin B Kompleks tablet 123.00 1400 1500 2,900 2,100 800 3000 1000 1,000 123,000.00
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 140 200 340 340 300 200 200 227,200.00
215 Vitamin B12 tablet 50 mcg tablet 52.00 1200 3000 4,200 3,100 1100 3000 3000 3,000 156,000.00
217 Vitamin B6 10 mg tablet 138.00 - - - -
Botol
218 Wida Bes Asetat Ringer (Asering) (Softbag, Flexy bag, plabot
Plastik
9,646.00 - - - -
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - - - -
OBAT GIZI (DAK 2019) - - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - -
221 Hemafort tablet 834.90 300 3600 3,900 3,900 10800 10800 10,800 9,016,920.00
Mineral Mix (Bismuth subcitrat tripotassium, copper sulfate,
222 magnesium chloride anhydrous, potassium chloride, zinc sachet 3,116.00 40 40 40 40 40 40 124,640.00
acetate)
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 100 100 100 100 100 100 32,400.00
224 Retnol Acetat/ Retinol (Vitamin A) Kaps Lunak 200.000 IU Kapsul 581.00 100 100 100 200 200 200 116,200.00
225 Allkohol 70% bottle 28,733.33 2 2 2 10 8 8 229,866.67
226 Alkohol 70% 1L botol 28,750.00 - - - -
227 Arm sling L buah 17,424.00 - - - -
228 Arm sling M buah 17,424.00 - - - -
229 Arm sling S buah 17,424.00 - - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - 50 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 15 15 15 20 - -
232 Aximed Syringe 1 cc Dus 103,750.00 - - 2 2 2 207,500.00
233 Aximed Syringe 3 cc Dus 103,125.00 7 10 17 15 2 10 10 10 1,031,250.00
234 Blood Lancet box 16,022.60 - - 10 10 10 160,226.00
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 14 12 26 26 24 24 24 872,160.00
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 20 12 32 32 24 24 24 992,760.00
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 14 24 38 38 24 24 24 872,160.00
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 20 20 20 20 - -
255 Dermafix T 10x12cm pcs 6,939.90 - - 50 50 50 346,995.00
256 Examination Gloves size L box 58,564.00 3 3 3 3 3 3 175,692.00
257 Examination Gloves size M box 58,564.00 3 3 3 3 3 3 175,692.00
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 - - - -
262 Germany Tro-Sensosurge Steril Glove 7.5 pasang 7,254.00 20 20 20 0 50 50 50 362,700.00
263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 20 20 20 0 50 50 50 362,700.00
267 Hb Sahli set 96,800.00 - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - -
270 Infuset pcs 6,166.16 20 20 40 40 50 50 50 308,308.00
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 20 20 20 50 50 50 408,254.00
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 20 20 20 20 20 20 161,777.00
276 Kapas pembalut 250 gr roll 13,750.00 5 10 15 15 10 10 10 137,500.00
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - - 100 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 15 100 115 115 100 100 100 176,000.00
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 60 100 160 160 100 100 100 165,000.00
282 Lysol 1 liter botol 47,150.00 - - 15 - -
284 Masker Tie on Box 19,869.00 - - - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
290 Onemed Blood Lancet box 16,022.60 1 1 1 300 - -
291 Onesept 500 ml botol 30,360.00 - - - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 10 10 10 - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 2 2 2 5 5 5 106,425.00
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 17 17 17 24 24 24 604,440.00
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 12 12 12 24 24 24 501,600.00
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 14 14 14 12 - -
300 Stera Infuset anak pcs 3,850.00 - - 50 - -
301 Surgical Mask Earloop box 18,150.00 5 5 5 10 - -
302 Surgical Mask Tie On box 18,150.00 5 5 5 10 - -
303 Swab 2 ply dus 14,040.84 - - - -
304 Syringe 10 cc dus 167,266.70 1 1 1 - -
305 Syringe 1cc pcs 1,045.80 80 100 180 180 - -
306 Syringe 1cc dus 106,523.56 - - - -
307 Syringe 3cc dus 107,421.38 - - - -
308 Syringe 5cc dus 119,090.61 1 1 1 - -
Tp. Infusion Set Pediatric 60 drops/ml with Y Type, Airvent,
313
Luer Lock
pcs 7,072.50 - - 50 50 50 353,625.00
318 Urine bag steril (t-valve) pcs 3,300.00 - - - -
319 HIV Device Box 707,143.00 12 12 12 12 8 8 5,657,144.00
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - - 120 120 120 737,040.00
VAKSIN - - - -
323 DPT-HB-Hib Vial 78,991.00 - - - -
324 DT Vial 17,996.00 - - - -
325 Hepatits B Buah 23,991.00 - - - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
326 IPV Vial 139,760.00 - - - -
327 IPV Vial 144,540.00 - - - -
328 MR Vial 141,648.00 - - - -
330 Td Vial 16,995.00 - - - -
ANTI RABIES - - - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - -
332 Albendazol 400 mg tablet 258.74 - - - -
OBAT GIZI - - - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - 5000 - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - 100 - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - 100 - -
336 Blood Slide Kotak 18,509.00 5 5 5 5 5 5 92,545.00
337 DHP Frimal tablet 3,498.00 - - - -
338 Kelambu GF Buah 61,077.00 - - - -
339 Primaquin 15 mg tablet 235.00 - - - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 10 10 10 - -
341 Ca. Glukonas Injeksi ampul 10,351.00 2 2 2 - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 5 5 5 - -
344 Methylergometrin Injeksi ampul 3,102.00 5 5 5 - -
345 MgSO4 20 % fls 3,328.00 12 12 12 - -
346 MgSO4 40 % fls 3,796.00 12 12 12 - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 16 16 16 25 25 25 65,000.00
OBAT TB PARU - - - -
350 Box Slide Kotak 41,342.00 - - - -
351 Kaca Slide Kotak 30,000.00 - - - -
352 Kaca Slide Kotak 20,747.00 - - - -
356 Pot Sputum Pot 2,500.00 1200 1,200 1,200 1200 - -
357 Reagen Ziehl Neelsen Kit 276,000.00 15 15 15 15 - -
358 Sputum Pot Buah 2,950.00 - - - -
359 Tuberkulin Vial 625,900.00 - - - -
KUSTA - - - -
360 MDT PB Dewasa Blister 12,569.00 - - - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
361 Paket ADRK II Paket 422,980.00 - - - -
IMUNISASI - - - -
362 ADS 0,05 ml Buah 1,518.00 - - - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - -
364 ADS 0,5 ml Buah 1,127.00 - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - -
369 ADS 5 ml buah 1,705.00 - - - -
370 ADS 5 ml Buah 1,705.00 - - - -
371 ADS 5 ml Buah 1,439.00 - - - -
372 ADS 5 ml Buah 1,500.00 - - - -
373 RCW Unit 2,266,454.00 - - - -
374 Safety Box pcs 16,608.00 - - - -
375 Safety Box 2,5 ml Buah 12,500.00 - - - -
376 Safety Box 5 ml Buah 20,394.00 - - - -
377 Vaccine Carrier buah 1,870,000.00 - - - -
378 Oseltamivir kapsul 12,969.00 - - - -
OBAT DIARE - - - -
380 Garam Oralit Sachet 253.00 100 100 100 - -
381 Zink Tablet tablet 551.00 500 500 500 500 500 500 275,500.00
382 Rapid 1 : SD HIV test 11,975.00 400 400 400 400 - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - -
384 Rapid Sifilis Ab test 20,400.00 - - - -
385 RPR Sifilis test 4,250.00 - - - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - 250 250 250 2,993,750.00
393 Rapid Sifilis Trepocheck test 9,697.00 150 150 150 150 - -
394 RPR Sifilis test 4,250.00 - - - -
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - 5 - -
397 L- Zinc botol 31,350.00 5 5 5 50 - -
398 Lagesil Suspensi botol 40,755.00 - - - -
REAGENTIA - - - -
REAGENSIA - - - -
401 Larutan Alkohol 96% botol 242,000.00 - - - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 1 1 1 3 3 3 7,896,000.00
410 Stick Pemeriksaan Asam Urat Box 1,384,600.00 - - - -
411 Stick Pemeriksaan Gula Darah Box 2,632,000.00 - - - -
DHP-Frimal Tablet 2,134.00 18 18 18 9 9 9 19,206.00
Alkohol 70% 1L botol 230,000.00 20 20 20 - -
One Med Povidone Iodine 60 ml botol 5,186.50 20 20 20 20 20 20 103,730.00
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1000 1000 1,000 110,000.00
Masker box 450,000.00 10 10 10 4,500,000.00
Handrub 500 ml botol 84,866.00 12 12 12 1,018,392.00
Alkohol 300 ml Bottle 80,000.00 10 10 10 800,000.00
tablet/kapsul/kaplet/kaptab 500 mg, salut 500 500 500 -
selaput
Lysol 1 liter botol 82,150.00 20 20 20 100 100 100 8,215,000.00
Fokus Diagnostis Syphilis Test 13,900.00 100 100 100 - -

Fokus New HIV 1/2 Test - 750 750 750 - -
TOTAL 76,245,592

JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr. Chairul Situmorang Nur Intan Munthe
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 NIP. 19830312 201001 2 016 Nip.19800811 201001 1 023 Nip. 19791128 201408 2 003
0
0
1000
0
100
1000
0
0
0
0
600 Du
0
700
100
60
3000
0
0
0
4500
0
100
50
48
0
0
0
0
0
0
0
0
0
0
0
0
0
0
48
0
0
0
0
500
100
0
100
700
0
0
50
500
0
100
0
5000
0
50
0
0
0
600
2800
0
0
0
0
500
0
0
0
1500
0
0
0
0
0
0
0
0
0
0
0
300
0
0
0
0
0
5
5
500
0
500
0
0
200
100
48
0
50
600
0
1000
0
100
0
0
0
1000
0
1000
0
200
0
300
0
24
0
50
0
0
4000
500
0
0
0
500
0
0
300
1500
0
0
0
0
0
40
700
0
0
48
20
0
0
500
0
300
0
0
0
0
0
200
0
0
4000
0
20
0
600
0
3000
1000
0
24
5
300
0
100
0
0
0
2000
2000
0
300
0
1000
0
150
0
0
100
0
0
0
500
0
0
48
0
0
0
1680
0
0
0
0
1000
300
1000
0
1500
200
3000
0
0
0
0
0
0
3600
40
100
100
0
0
0
0
0
0
0
0
0
10
0
0
0
0
0
0
0
0
0
12
12
0
24
20
20
20
0
0
0
0
0
0
3
3
0
0
0
0
20
20
0
0
0
0
0
0
20
20
20
0
0
0
10
0
100
100
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
2
0
12
0
0
5
5
0
1
100
0
0
1
0
0
0
0
0
0
0
0
0
0
0
12
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1200
15
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
400
0
0
0
0
0
0
0
0
0
0
0
0
150
0
0
0
0
0
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
9
10
10
10
50
375
DINKES
PUSKESMAS : KAMPUNG MESJID LAPORAN TRIWULAN : I (II) III IV GFK 13/IFK/3/2020 16-Sep-20
KECAMATAN : KUALUH HILIR PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 1,100 1,100 200 900 - - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - - - - - -
3 Alopurinol tablet 100 mg tablet 97.00 2,600 2,000 4,600 3,400 1,200 1,500 1,500 1,500 3,000 291,000
5 Ambroxol 15 mg/5 ml botol 6,600.00 140 140 77 63 200 200 200 400 2,640,000
6 Ambroxol tab 30 mg tablet 330.00 1,800 2,000 3,800 3,300 500 2,000 2,000 2,000 4,000 1,320,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 60 60 5 55 30 - - -
8 Aminofilin tablet 200 mg tablet 92.00 500 500 500 300 - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 300 300 - 300 - - -
11 tablet 78.00 600 600 - 1,200 1,200 1,200 2,400 187,200
600
12 Kaplet 94.00 600 600 - 300 300 300 600 56,400
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 1,000 1,000 - 1,000 - - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 40 100 140 136 4 100 100 100 200 1,320,000
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 102 120 222 177 45 60 60 60 120 440,400
17 kaptab 261.00 39 5,000 5,039 4,839 200 5,000 5,000 5,000 10,000 2,610,000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 8 8 - 8 - - -
20 Antasida Tablet tablet 200.00 6,900 6,900 4,800 2,100 - - -
21 Antasida Tab Tablet 355.00 5,000 5,000 - 5,000 5,300 5,300 5,300 10,600 3,763,000
Page 145
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
22 tablet 60.00 - - - - - -
23 botol 2,189.00 100 100 200 200 - 100 100 100 200 437,800

+ Polimiksin 10.000
3,071.00
IU/g 10 10 5 5 - - -

25 pot 4,540.00 30 24 54 21 33 24 24 24 48 217,920
Asam Salisilat 3%

26 3,325.00 - - - - - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 10 10 3 7 - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 650 650 300 350 - - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 8 8 2 6 10 10 10 20 30,800
33 Bedak salisil serbuk 2% dus 1,040.00 44 44 44 - - - -
34 Bedak Salisil Kotak 8,000.00 30 30 5 25 30 30 30 60 480,000
35 Betametason krim 0,5 mg/g tube 3,388.00 36 36 36 - - - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 25 25 50 36 14 50 25 25 50 67,000
37 Ampul 130,999.00 - - - - - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - - - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 150 150 - 150 - - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 48 48 48 - - - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 48 48 96 63 33 96 96 96 192 602,496
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - 1,000 - - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - 20 - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - - -
tablet
46 Cetirizin Hydrochloride salut 94.00 - - - - - - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 600 1,000 1,600 1,600 - 2,000 300 300 600 60,600
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 40 50 90 67 23 100 100 100 200 594,600
Page 146
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
50 salut 165.00 100 100 - 100 - - -
selaput
51 kapsul 770.00 - - - - 500 500 500 1,000 770,000
52 Codeine 10 mg tablet 600.00 100 - 100 - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 92 50 142 102 40 50 50 50 100 219,000
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 700 1,000 1,700 1,400 300 1,000 700 700 1,400 186,200
56 tablet 47.00 - - - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 560 50 610 270 340 250 240 240 480 552,960
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 6,400 6,000 12,400 9,400 3,000 3,000 - - -
61 Dekstrofen Syrup Botol 11,550.00 39 100 139 139 - 150 - - -
62 Diazepam 2 mg Tablet 86.00 200 200 - 200 - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 30 10 40 40 - 10 - - -
65 Diclofenac Sodium 25 mg Tablet 141.00 - - - - - -
66 Diclofenac Sodium 50 mg Tablet 136.00 2,800 2,800 2,500 300 5,600 5,600 5,600 11,200 1,523,200
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 540 540 540 - - - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 300 300 - 300 300 300 300 345,300
70 Digoksin tablet 0,25 mg tablet 106.00 500 500 500 - - - -
71 Digoksin 0,25 mg Tablet 104.00 300 300 - 300 - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - - - 1,000 - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 132 132 40 92 - - -
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 500 500 500 - - - -
Page 147
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
75 Domperidon tablet 10 mg tablet 86.00 1,000 1,000 2,000 700 1,300 1,500 1,000 1,000 2,000 172,000
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 12 12 - 12 - - -
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 12 12 - 12 - - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 11 11 11 - 10 - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 500 500 - 500 - - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 900 900 900 - - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 6 6 - 6 20 - - -
83 Eugenol cairan botol 21,091.00 - - - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 300 300 - 300 - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 14 14 5 9 25 - - -
87 tablet 747.00 300 300 300 - - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 300 500 800 - 800 500 200 200 400 318,800
89 ampul 3,867.00 90 60 150 72 78 - - -
mg/ml
91 Furosemid Inj 10 mg/ml ampul 1,333.00 25 25 25 - 25 25 25 50 66,650
92 Furosemide tablet 40 mg tablet 77.00 - - - 1,000 - - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 15 15 15 - - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 20 18 38 23 15 24 10 10 20 56,200
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - - - 50 10 10 20 89,040
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1,500 500 2,000 1,300 700 500 500 500 1,000 125,000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 - - - 20 - - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 1,200 500 1,700 1,000 700 500 500 500 1,000 245,000
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - - -

101 Haloperidol 0,5 mg Tablet 55.00 500 500 - 500 - - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - - - -
103 Hidrokortison krim 2,5 % tube 2,640.00 48 24 72 34 38 48 48 48 96 253,440
Page 148
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
105 Hustab Syrup botol 11,550.00 100 150 250 250 - 150 100 100 200 2,310,000
106 Hustab P Tablet 8 mg Tablet 256.67 900 1,500 2,400 1,500 900 1,500 1,500 1,500 3,000 770,010
107 Hustab Tablet tablet 437.00 300 600 900 700 200 3,600 3,600 3,600 7,200 3,146,400
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 400 400 300 100 - -
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 500 500 500 - - -
selaput
110 Ibuprofen 200 mg Tablet 550.00 1,300 1,300 - 1,300 1,000 1,000 1,000 2,000 1,100,000
111 Ibuprofen 400 mg Tablet 800.00 400 700 1,100 1,100 - 3,000 500 500 1,000 800,000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 128 128 44 84 - - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 50 50 - 50 50 50 50 100 277,600
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 600 600 - 600 - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - - - -

116 tablet 63.00 1,800 2,000 3,800 2,800 1,000 2,000 2,000 2,000 4,000 252,000
118 Kaptopril 12,5 mg tablet 68.00 300 500 800 700 100 - - -
119 Ketokenazol tablet 200 mg tablet 278.00 50 50 50 - - - -
120 Ketokonazol tablet 200 mg tablet 297.00 200 200 400 - 400 500 - - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 1,100 1,100 200 900 1,000 - - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - - 500 500 500 1,000 660,000
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 24 24 48 15 33 48 48 48 96 192,672
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 71 71 58 13 - - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 50 50 - 50 50 50 50 100 516,800
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 5,400 5,400 5,400 - - - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - - -
129 Klorfeniramin maleat tablet 25.00 5,000 5,000 - 5,000 5,000 5,000 5,000 10,000 250,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 2,000 2,000 2,000 - 2,000 1,000 1,000 2,000 606,000
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 480 480 480 - - - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 160 160 60 100 100 - - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 400 600 1,000 400 600 1,000 300 300 600 156,000
Page 149
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
134 Meloksikam 7,5 mg tablet 795.68 600 600 600 - 1,000 - - -
135 Meloxicam tab15 mg tablet 1,438.80 700 800 1,500 1,400 100 2,000 1,500 1,500 3,000 4,316,400
136 Meloxicam 15 mg Tablet 980.00 - - - - - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 600 600 400 200 - - -
138 tablet 137.00 1,900 2,000 3,900 3,600 300 3,000 - - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - - - 2,000 2,000 2,000 4,000 584,000

tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 100 100 - 100 - - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 400 400 100 300 300 300 300 600 48,000
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 15 10 25 7 18 - - -
146 Metronidazole tablet 500 mg tablet 264.00 500 700 1,200 1,100 100 2,000 600 600 1,200 316,800
147 MgSO4 20 % botol 13,500.00 12 12 3 9 12 - - -
148 MgSO4 40 % botol 13,500.00 12 12 3 9 12 - - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 34 48 82 82 - 48 48 48 96 344,160
150 NaCl 0,9 % 500 ml botol 6,840.00 32 20 52 32 20 20 20 20 40 273,600
151 tablet 132.00 800 800 500 300 - - -
25 mg
152 tablet 127.00 1,400 1,400 1,100 300 - - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 1,800 1,000 2,800 2,200 600 1,000 - - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 700 700 500 200 - - -
155 Nystatin tablet 500.000 IU Tablet 886.00 300 300 - 300 - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - - -
161 Omeprazol Tab Tablet 650.00 - - - 2,000 400 400 800 520,000
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 5 5 5 - 10 - - -
Page 150
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
163 Paracetamol Tab 500 mg tablet 290.00 - - - - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 2,000 5,200 7,200 2,000 5,200 5,200 5,200 5,200 10,400 1,716,000
165 bottle 6,981.00 20 20 20 - 10 - - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 45 30 75 75 - 100 - - -
167 Pehacain Injeksi ampul 3,113.06 80 80 80 - - - -
168 Pehacain Injeksi Ampul 3,113.05 180 300 480 180 300 300 300 300 600 1,867,830
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - - - - -
170 Pehastan 500 mg tablet 445.50 3,200 3,400 6,600 6,500 100 5,000 2,500 2,500 5,000 2,227,500
171 Pehavral tablet 935.00 900 1,000 1,900 1,800 100 1,000 - - -
172 Perak sulfadiazin krim 1% tube 20,700.00 20 20 6 14 10 - - -
173 Peridol Syrup 60 ml botol 19,800.00 - - - - - -
174 botol 124,355.00 3 3 - 3 - - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 100 500 600 600 - 1,000 1,000 1,000 2,000 1,760,000
176 tablet 302.00 300 300 300 - - - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 200 100 300 - 300 100 100 100 200 64,400
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 35 35 25 10 - - -
179 Pirantel Pamoat syrup botol 10,778.00 5 5 - 5 30 - - -
180 Tablet 124.00 6,100 6,100 6,100 - - - -
(HCl)
181 tablet 129.00 500 1,000 1,500 500 1,000 2,000 2,000 2,000 4,000 516,000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 1,000 1,000 2,000 1,300 700 1,000 1,000 1,000 2,000 152,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 400 400 400 - - - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 1,250 500 1,750 1,600 150 1,000 200 200 400 56,800
185 Pyridol Syrup 60 ml botol 18,150.00 112 112 24 88 - - -
186 Ranitidin 150 mg Tablet tablet 660.00 2,400 1,000 3,400 3,400 - 5,000 1,500 1,500 3,000 1,980,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 250 250 250 - - - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 200 200 400 90 310 300 300 300 600 693,000
191 Ringer Laktat 500 ml botol 7,630.00 140 140 140 - 400 400 400 800 6,104,000
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 1,000 1,000 300 700 - - -
Page 151
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
194 Salbutamol 2 mg tab tablet 67.00 - - - - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,700 1,000 2,700 2,100 600 2,000 2,000 2,000 4,000 320,000
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - - - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 15 18 33 33 - 50 20 20 40 177,840
198 pot 2,654.00 48 48 96 79 17 72 72 72 144 382,176
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 300 600 900 900 - 1,000 600 600 1,200 1,452,000
200 Seftriakson serb inj 1.000 mg vial 4,998.00 20 20 - 20 100 100 100 200 999,600
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - - - - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - - - - - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 300 1,680 1,980 300 1,680 3,360 3,360 3,360 6,720 786,240
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 2,100 2,100 2,100 - - - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 5 5 1 4 - - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 5 5 1 4 - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 500 500 300 200 1,000 - - -
208 tablet 84.00 1,200 1,000 2,200 1,800 400 1,000 1,000 1,000 2,000 168,000
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - - - - - -
tablet
210 salut 93.00 100 100 - 100 - - -
selaput
211 Vapril 25 mg tablet 193.00 500 500 300 200 3,000 3,000 3,000 6,000 1,158,000
212 box 6,550.00 - - - - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,800 1,500 3,300 3,300 - 3,000 1,500 1,500 3,000 369,000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 150 300 450 450 - 500 300 300 600 681,600
215 Vitamin B12 tablet 50 mcg tablet 52.00 3,200 2,000 5,200 3,600 1,600 2,000 2,000 2,000 4,000 208,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - - -
217 Vitamin B6 10 mg tablet 138.00 - - - - - -
218 9,646.00 - - - - - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 24 24 12 12 24 - - -
OBAT GIZI (DAK 2019) - - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - - -
Page 152
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
221 Hemafort tablet 834.90 1,700 3,600 5,300 5,300 - 7,200 7,200 7,200 14,400 12,022,560
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 - - - - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - - -
224 Kapsul 581.00 - - - - - -
IU
225 Allkohol 70% bottle 28,733.33 5 5 3 2 10 - - -
226 Alkohol 70% 1L botol 28,750.00 8 8 8 - - - -
227 Arm sling L buah 17,424.00 9 9 - 9 - - -
228 Arm sling M buah 17,424.00 9 9 - 9 - - -
229 Arm sling S buah 17,424.00 9 9 - 9 - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 5 5 5 - 10 - - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 22 22 12 10 10 - - -
232 Aximed Syringe 1 cc Dus 103,750.00 10 10 10 - 5 5 5 10 1,037,500
233 Aximed Syringe 3 cc Dus 103,125.00 33 5 38 38 - 5 5 5 10 1,031,250
234 Blood Lancet box 16,022.60 3 5 8 - 8 5 5 5 10 160,226
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 12 12 - 12 - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 10 10 10 - - - -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 36 36 - 36 - - -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 24 24 48 24 24 - - -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 36 36 - 36 - - -
Page 153
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 20 10 30 30 - - - -
250 Catheter Tro-Venocath, Sine 26 G pcs 23,843.00 10 10 20 - 20 - - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - 50 27 27 54 280,692
255 Dermafix T 10x12cm pcs 6,939.90 20 10 30 20 10 10 10 10 20 138,798
256 Examination Gloves size L box 58,564.00 - - - - - -
257 Examination Gloves size M box 58,564.00 - - - - - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 9 10 19 13 6 10 10 10 20 748,800
260 Folley catheter 2 way no. 16 pcs 8,800.00 10 10 - 10 - - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 200 200 70 130 - - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - -
267 Hb Sahli set 96,800.00 - - - - - -
268 Hidrogen Peroxide 3% botol 3,864.00 - - - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - 5 - - -
270 Infuset pcs 6,166.16 25 50 75 75 - 100 50 50 100 616,616
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 15 20 35 5 30 20 10 10 20 163,302
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 15 20 35 35 - 100 50 50 100 808,885
273 IV- Cath WP, with wings & port no 24 pcs 8,088.85 - - - 100 20 20 40 323,554
274 IV- Cath WP, with wings & port no 26 pcs 10,477.39 15 10 25 - 25 - - -
275 Kapas pembalut 250 gr roll 13,733.33 9 9 9 - - - -
276 Kapas pembalut 250 gr roll 13,750.00 5 5 - 5 5 5 5 10 137,500
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 30 30 15 15 30 - - -
Page 154
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
278 Kasa kompres steril 40 x 40 pcs 1,760.00 200 100 300 200 100 200 67 67 134 235,840
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 80 50 130 80 50 50 50 50 100 165,000
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - - - - -
282 Lysol 1 liter botol 47,150.00 3 3 3 - 10 - - -
283 Masker Ear Loop Box 20,202.00 2 2 2 - - - -
284 Masker Tie on Box 19,869.00 - 10 10 10 - 20 - - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 5 5 1 4 - - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 5 5 1 4 - - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 5 5 1 4 - - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 5 5 1 4 - - -
289 Onemed Alcohol Swab botol 11,000.00 8 10 18 8 10 10 10 10 20 220,000
290 Onemed Blood Lancet box 16,022.60 - - - - - -
291 Onesept 500 ml botol 30,360.00 3 3 3 - - - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 20 20 - 20 - - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - - -
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 20 20 10 10 - - -
295 Safeglove Examination Gloves L box 39,182.00 - - - - - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 10 10 2 8 - - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 25 25 13 12 - - -
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 45 45 33 12 - - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 20 36 56 8 48 - - -
300 Stera Infuset anak pcs 3,850.00 36 36 36 - - - -
301 Surgical Mask Earloop box 18,150.00 2 2 2 - - - -
302 Surgical Mask Tie On box 18,150.00 12 12 12 - 10 - - -
303 Swab 2 ply dus 14,040.84 - - - - - -
304 Syringe 10 cc dus 167,266.70 - - - - - -
305 Syringe 1cc pcs 1,045.80 900 500 1,400 1,000 400 - - -
306 Syringe 1cc dus 106,523.56 - - - - - -
307 Syringe 3cc dus 107,421.38 - - - - - -
Page 155
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
308 Syringe 5cc dus 119,090.61 - - - - - -
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - - -
312 Tp. Disposable Syringe 5 cc pcs 892.78 100 100 100 - - - -

313 pcs 7,072.50 15 50 65 5 60 - - -
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - - -
318 Urine bag steril (t-valve) pcs 3,300.00 3 3 - 3 - - -
319 HIV Device Box 707,143.00 16 16 - 16 - - -
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 24 24 - 24 - - -
VAKSIN - - - -
321 BCG +Pelarut BCG Vial 61,996.00 - - - - - -
322 Campak + Pelarut Campak Vial 28,204.00 - - - - - -
323 DPT-HB-Hib Vial 78,991.00 - - - - - -
324 DT Vial 17,996.00 - - - - - -
325 Hepatits B Buah 23,991.00 - - - - - -
326 IPV Vial 139,760.00 - - - - - -
327 IPV Vial 144,540.00 - - - - - -
328 MR Vial 141,648.00 - - - - - -
329 Polio+ Dropper Polio Vial 19,954.00 - - - - - -
330 Td Vial 16,995.00 - - - - - -
ANTI RABIES - - - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - - -
Page 156
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
332 Albendazol 400 mg tablet 258.74 - - - - - -
OBAT GIZI - - - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - - -
336 Blood Slide Kotak 18,509.00 5 5 2 3 - - -
337 DHP Frimal tablet 3,498.00 - - - - - -
338 Kelambu GF Buah 61,077.00 - - - - - -
339 Primaquin 15 mg tablet 235.00 - - - - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - - -
342 Euthyrox 50 mcg tablet 735.00 - - - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - - - - - -
344 Methylergometrin Injeksi ampul 3,102.00 20 20 - 20 - - -
345 MgSO4 20 % fls 3,328.00 - - - - - -
346 MgSO4 40 % fls 3,796.00 - - - - - -
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - - - 50 50 50 100 260,000
OBAT TB PARU - - - - -
350 Box Slide Kotak 41,342.00 - - - - - -
351 Kaca Slide Kotak 30,000.00 - - - - - -
352 Kaca Slide Kotak 20,747.00 - - - - - -
354 OAT Kategori I Paket 377,900.00 - - - - - -
Page 157
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
356 Pot Sputum Pot 2,500.00 1,000 1,000 - 1,000 - - -
357 Reagen Ziehl Neelsen Kit 276,000.00 14 14 - 14 - - -
358 Sputum Pot Buah 2,950.00 - - - - - -
359 Tuberkulin Vial 625,900.00 - - - - - -
KUSTA - - - - -
360 MDT PB Dewasa Blister 12,569.00 - - - - - -
361 Paket ADRK II Paket 422,980.00 - - - - - -
IMUNISASI - - - -
362 ADS 0,05 ml Buah 1,518.00 - - - - - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - - -
364 ADS 0,5 ml Buah 1,127.00 - - - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - -
369 ADS 5 ml buah 1,705.00 - - - - - -
370 ADS 5 ml Buah 1,705.00 - - - - - -
371 ADS 5 ml Buah 1,439.00 - - - - - -
372 ADS 5 ml Buah 1,500.00 - - - - - -
373 RCW Unit 2,266,454.00 - - - - - -
374 Safety Box pcs 16,608.00 - - - - - -
378 Oseltamivir kapsul 12,969.00 - - - - - -
OBAT DIARE - - - -
379 Garam Oralit Sachet 257.00 - - - - - -
380 Garam Oralit Sachet 253.00 200 200 - 200 - - -
Page 158
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
381 Zink Tablet tablet 551.00 500 500 1,000 600 400 500 500 500 1,000 551,000
382 Rapid 1 : SD HIV test 11,975.00 500 500 300 200 - - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - - -
384 Rapid Sifilis Ab test 20,400.00 - - - - - -
385 RPR Sifilis test 4,250.00 - - - - - -
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - 125 125 125 250 2,993,750
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - - -
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - - -
391 Rapid 3 Diagnostar test 13,771.00 - - - - - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - - -
393 Rapid Sifilis Trepocheck test 9,697.00 75 75 - 75 - - -
394 RPR Sifilis test 4,250.00 - - - - - -
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - 100 - - -
397 L- Zinc botol 31,350.00 13 5 18 11 7 10 - - -
398 Lagesil Suspensi botol 40,755.00 14 14 14 - 40 - - -
REAGENTIA - - - -
399 Objek Gelas Kotak 50,000.00 - - - - - -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - - -
REAGENSIA - - - -
401 Larutan Alkohol 96% botol 242,000.00 - - - - - -
402 Larutan Metanol botol 665,500.00 - - - - - -
Page 159
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
403 Reagen Benedict botol 484,000.00 - - - - - -
404 Reagen Natrium Sitrat botol 514,250.00 - - - - - -
405 Reagen Receker botol 2,238,500.00 - - - - - -
406 Reagensia Asam Asetat botol 544,500.00 - - - - - -
407 Slide test widal Unit 302,500.00 - - - - - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 1 1 - 1 3 3 3 6 15,792,000
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - - - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - - -

Alkohol 70% 1L botol 230000 10 10 5 5 - -
Lysol 1 liter botol 82150 10 10 10 - 100 100 100 8,215,000
One Med Povidone Iodine 60 ml botol 5186.5 30 30 10 20 20 20 20 103,730
Fokus Diagnostis Syphilis Test 13900 75 75 - 75 - -
Fokus New HIV 1/2 Test 250 250 - 250 - -
DHP-Frimal Tablet 2134 9 9 - 9 45 45 45 96,030
Asam Askorbat (Vit C) tab 50 mg tablet 110 2,000 2,000 400 1,600 2,000 1,000 1,000 110,000
Masker box 450,000.00 10 10 10 4,500,000
Alkohol 70% 300 ml botol 80,000.00 5 5 5 400,000
Hand Sanitizer 20 20 20 -
TOTAL Rp 112,434,467
Yang Menerima
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Rosmaida Uli Nababan RITA
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip.197006201993012001 Nip. 19740513 201408 2 001
Page 160
-
-
2,000
-
-
2,000
-
-
-
-
-
1,000
100
120
5,000
-
-
-
5,000
Page 161
-
100
24
-
-
-
-
-
-
-
30
-
25
-
48
-
-
-
-
1,000
50
-
Page 162
100
-
-
50
1,000
50
-
6,000
-
100
-
-
10
-
2,800
-
300
-
-
300
Page 163
1,000
-
-
-
-
-
-
-
-
-
500
60
-
-
-
-
18
500
500
-
-
-
-
24
Page 164
-
150
1,500
600
1,300
700
-
50
2,000
-
500
-
200
-
-
-
24
-
50
-
-
5,000
2,000
-
-
600
Page 165
-
800
-
2,000
-
-
-
-
-
10
700
-
-
48
20
1,000
-
300
-
-
-
-
-
-
-
Page 166
-
5,200
30
-
300
-
3,400
1,000
-
-
500
100
-
-
1,000
1,000
-
500
-
1,000
-
200
-
-
-
-
-
Page 167
-
1,000
-
18
48
600
-
-
1,680
-
-
-
1,000
1,500
300
2,000
-
-
-
-
28,000
Page 168
3,600
-
-
-
-
-
-
-
-
5
5
-
-
-
-
-
-
-
-
24
-
-
36
-
Page 169
-
10
10
-
-
-
-
10
-
-
-
10
-
-
-
-
-
-
-
-
-
-
100
20
20
20
10
-
5
30
Page 170
100
50
-
-
-
-
10
-
-
-
-
10
-
-
-
-
-
-
-
-
-
36
-
2
12
-
-
500
-
-
Page 171
-
-
-
-
-
50
-
-
-
-
-
-
16
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 172
-
-
-
-
-
-
-
5
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 173
1,000
14
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 174
500
-
200
-
-
-
-
-
-
-
-
-
-
-
-
75
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 175
-
-
-
-
-
-
1
-
-
-
-
10
10
30
75
250
9
2,000
Page 176
DINKES
PUSKESMAS : AEK KORSIK LAPORAN TRIWULAN : I (II) III IV GFK 12/IFK/3/2020 15-Sep-20
KECAMATAN : AEK KUO PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 - - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - 500 500 500 - 1,200 - -
3 Alopurinol tablet 100 mg tablet 97.00 800 1,500 2,300 1,400 900 1,500 1,000 1,000 97,000
5 Ambroxol 15 mg/5 ml botol 6,600.00 40 100 140 90 50 250 150 150 990,000
6 Ambroxol tab 30 mg tablet 330.00 900 1,500 2,400 1,500 900 2,000 2,000 2,000 660,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 6 - 6 - 6 - - -
8 Aminofilin tablet 200 mg tablet 92.00 200 200 - 200 - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 - - -
11 tablet 78.00 - 900 900 600 300 2,100 2,100 2,100 163,800
12 Kaplet 94.00 300 300 90 210 300 300 300 28,200
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - - - - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 10 120 130 90 40 120 120 120 440,400
17 kaptab 261.00 1,500 3,500 5,000 3,100 1,900 5,000 5,000 5,000 1,305,000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 20 20 - 20 - - -
20 Antasida Tablet tablet 200.00 900 - 900 900 - - - -
21 Antasida Tab Tablet 355.00 - 4,000 4,000 1,700 2,300 4,000 3,000 3,000 1,065,000
22 tablet 60.00 - - - - -
Page 177
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
23 botol 2,189.00 - 100 100 59 41 100 100 100 218,900

+ Polimiksin 10.000
3,071.00
IU/g - - - - - -

25 pot 4,540.00 24 14 38 - 38 72 72 72 326,880
Asam Salisilat 3%

26 3,325.00 48 48 - 48 - - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 10 10 - 10 - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 300 300 - 300 - - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - 500 500 350 150 - - -
33 Bedak salisil serbuk 2% dus 1,040.00 24 - 24 20 4 - - -
34 Bedak Salisil Kotak 8,000.00 - 10 10 - 10 50 30 30 240,000
35 Betametason krim 0,5 mg/g tube 3,388.00 - - - - - - - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - 50 50 24 26 50 25 25 33,500
37 Ampul 130,999.00 - - - - - 1 1 1 130,999
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - - - 1 1 1 512,204
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - 60 60 - 60 - - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 - - - - - - - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 48 72 120 72 48 72 72 72 225,936
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - - - - - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - - - - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - - - - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - - - - -
tablet
46 Cetirizin Hydrochloride salut 94.00 - - - - - - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - 1,000 1,000 1,000 - 3,000 300 300 30,300
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 - 100 100 20 80 100 100 100 297,300
tablet
50 salut 165.00 100 - 100 - 100 100 100 100 16,500
selaput
51 kapsul 770.00 - 1,000 1,000 600 400 1,000 1,000 1,000 770,000
Page 178
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
52 Codeine 10 mg tablet 600.00 400 - 400 - 400 - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 30 50 80 48 32 50 50 50 109,500

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 500 700 1,200 600 600 1,200 600 600 79,800
56 tablet 47.00 - - - - - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 - 100 100 60 40 240 240 240 276,480
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - - - - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 500 1,500 2,000 1,200 800 1,200 - - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - - - - -
61 Dekstrofen Syrup Botol 11,550.00 - 50 50 10 40 100 - -
62 Diazepam 2 mg Tablet 86.00 - 100 100 - 100 100 - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 10 - 10 - 10 - - -
65 Diclofenac Sodium 25 mg Tablet 141.00 - - - - - - - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - 2,800 2,800 2,650 150 5,600 5,600 5,600 761,600
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - 60 60 36 24 30 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - - - - - 60 60
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - - - - -
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - - - - -
71 Digoksin 0,25 mg Tablet 104.00 - - - - - - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - - - - - - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 50 - 50 - 50 60 50 50 139,050
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 400 400 200 200 - -
75 Domperidon tablet 10 mg tablet 86.00 - 1,000 1,000 300 500 1,200 1,000 1,000 86,000
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - - - - -
Page 179
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
kaptab
80 Eritromisin kapl 500 mg salut 765.00 - - - - - - - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - - - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 40 - 40 36 4 - - -
83 Eugenol cairan botol 21,091.00 2 - 2 1 1 5 - -
84 Fenobarbital tablet 30 mg tablet 165.00 600 - 600 - 600 - - -
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - - - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - - - 48 - -
87 tablet 747.00 500 - 500 - 500 - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 - - - - - - - -
89 ampul 3,867.00 - 30 30 10 20 30 30 30 116,010
mg/ml
90 Fituno Tab tablet 4,163.10 - - - - - 60 60 60 249,786
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - 25 25 24 1 - - -
92 Furosemide tablet 40 mg tablet 77.00 200 - 200 - 200 200 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - - 20 - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - - - 12 12 12 33,720
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 10 24 34 20 14 48 12 12 53,424
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 700 2,000 2,700 1,200 1,500 1,000 1,000 1,000 125,000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 20 20 - 20 20 - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 400 200 600 400 200 500 500 500 122,500
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - - - - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - - - - -
101 Haloperidol 0,5 mg Tablet 55.00 100 - 100 - 100 - - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 100 - 100 - 100 - - -
103 Hidrokortison krim 2,5 % tube 2,640.00 - 48 48 48 - 48 48 48 126,720
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - - - - -
105 Hustab Syrup botol 11,550.00 40 50 90 45 45 100 100 100 1,155,000
106 Hustab P Tablet 8 mg Tablet 256.67 300 3,000 3,300 1,500 1,800 1,200 1,200 1,200 308,004
107 Hustab Tablet tablet 437.00 - 1,500 1,500 1,200 300 3,600 3,600 3,600 1,573,200
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - 1,000 1,000 200 800 400
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 - - - - - -
selaput
Page 180
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
110 Ibuprofen 200 mg Tablet 550.00 - - - - - 1,500 1,500 1,500 825,000
111 Ibuprofen 400 mg Tablet 800.00 500 500 200 300 1,000 500 500 400,000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 10 10 10 - - - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - 50 50 26 24 100 50 50 138,800
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 200 1,200 1,400 100 1,300 - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - - - - - -

116 tablet 63.00 900 1,000 1,900 600 1,300 1,000 1,000 1,000 63,000
117 Kanamycin 1 gr inj vial 10,768.00 - - - - - - - -
118 Kaptopril 12,5 mg tablet 68.00 500 500 1,000 200 800 1,500 1,500 1,500 102,000
119 Ketokenazol tablet 200 mg tablet 278.00 - - - - - 1,700 - -
120 Ketokonazol tablet 200 mg tablet 297.00 - - - - - - - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 500 - 500 350 150 - - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - - - - - - -
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - - - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 24 24 48 24 24 48 48 48 96,336
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - - - - - - - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - 50 50 22 28 100 50 50 258,400
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 900 - 900 - 900 - - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - - - - -
129 Klorfeniramin maleat tablet 25.00 - 1,000 1,000 300 700 2,000 2,000 2,000 50,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - - - - - 500 500 500 151,500
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 500 - 500 - 500 500 - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 - 100 100 50 50 - - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 - 500 500 - 500 2,000 300 300 78,000
134 Meloksikam 7,5 mg tablet 795.68 700 700 400 300 1,200 - -
135 Meloxicam tab15 mg tablet 1,438.80 400 1,000 1,400 1,400 - 1,000 700 700 1,007,160
136 Meloxicam 15 mg Tablet 980.00 - - - - - - - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 - 1,000 1,000 200 800 1,200 - -
138 tablet 137.00 1,000 - 1,000 1,000 - 2,500 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - - - - - 1,500 1,500 1,500 219,000
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - - - - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - - - - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 500 - 500 - 500 - - -
selaput
Page 181
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - - - - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 1,100 500 1,600 900 700 500 500 500 40,000
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 5 10 15 - 15 50 50 50 197,500
146 Metronidazole tablet 500 mg tablet 264.00 1,200 500 1,700 1,400 300 1,000 700 700 184,800
147 MgSO4 20 % botol 13,500.00 - - - - - - - -
148 MgSO4 40 % botol 13,500.00 - - - - - - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 72 - 72 - 72 - - -
150 NaCl 0,9 % 500 ml botol 6,840.00 18 - 18 10 8 60 60 60 410,400
151 tablet 132.00 2,000 - 2,000 200 1,800 - - -
25 mg
152 tablet 127.00 1,000 - 1,000 1,000 - - - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 2,800 - 2,800 1,200 1,600 - - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 - - - Err:522 Err:522 300 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - - - Err:522 Err:522 200 200 200 177,200
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - Err:522 Err:522 - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - Err:522 Err:522 - - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - Err:522 Err:522 - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - Err:522 Err:522 - - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - Err:522 Err:522 30 - -
161 Omeprazol Tab Tablet 650.00 - 400 400 - 400 1,000 200 200 130,000
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - - - - - - - -
163 Paracetamol Tab 500 mg tablet 290.00 - - - - - - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 1,900 4,000 5,900 3,000 2,900 5,600 5,600 5,600 924,000
165 bottle 6,981.00 - - - - - 50 - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 10 30 40 40 - 100 - -
167 Pehacain Injeksi ampul 3,113.06 - - - - - - - -
168 Pehacain Injeksi Ampul 3,113.05 100 300 400 - 400 220 220 220 684,871
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - - - -
170 Pehastan 500 mg tablet 445.50 - 3,000 3,000 2,200 800 3,000 2,000 2,000 891,000
171 Pehavral tablet 935.00 - 2,000 2,000 - 2,000 - - -
172 Perak sulfadiazin krim 1% tube 20,700.00 18 - 18 - 18 20 - -
173 Peridol Syrup 60 ml botol 19,800.00 - 10 10 10 50 - -
174 botol 124,355.00 - - - - - - - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 200 1,000 1,200 600 600 900 900 900 792,000
Page 182
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
176 tablet 302.00 - - - - - - - - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 - 100 100 100 - 100 100 100 32,200
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - - - - - - - -
179 Pirantel Pamoat syrup botol 10,778.00 - - - - - 20 - -
180 Tablet 124.00 - 1,000 1,000 600 400 500 - -
(HCl)
181 tablet 129.00 500 - 500 - 500 1,000 1,000 1,000 129,000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 - 1,500 1,500 500 1,000 1,000 1,000 1,000 76,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 - - - - - - - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 1,000 500 1,500 600 900 500 200 200 28,400
185 Pyridol Syrup 60 ml botol 18,150.00 - - - - - - - -
186 Ranitidin 150 mg Tablet tablet 660.00 1,000 800 1,800 1,300 500 3,000 600 600 396,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - - - - - - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 - 100 100 15 85 - - -
191 Ringer Laktat 500 ml botol 7,630.00 16 40 56 24 32 40 40 40 305,200
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - - - - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 100 1,000 1,100 - 1,100 6,000 2,000 2,000 126,000
194 Salbutamol 2 mg tab tablet 67.00 - - - - - - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,000 1,500 2,500 2,000 500 2,000 2,000 2,000 160,000
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - - - - - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - - - - 10 10 10 44,460
198 pot 2,654.00 - - - - - 72 72 72 191,088
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 500 500 1,000 900 100 500 500 500 605,000
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - - - - - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - - - - - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - - - - - - - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 - 1,680 1,680 1,680 - 3,360 3,360 3,360 393,120
tablet
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 10 - 10 10 - - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - - 5 5 5 95,965
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 600 600 - 600 - - -
Page 183
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
208 tablet 84.00 700 600 1,300 600 700 500 500 500 42,000
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - - - - - - - -
tablet
210 salut 93.00 - 100 100 - 100 - - -
selaput
211 Vapril 25 mg tablet 193.00 - 1,000 1,000 400 600 2,000 2,000 2,000 386,000
212 box 6,550.00 20 - 20 - 20 - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,000 1,000 2,000 1,000 1,000 2,500 1,000 1,000 123,000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 - - - - - - - -
215 Vitamin B12 tablet 50 mcg tablet 52.00 800 1,500 2,300 1,200 1,100 2,000 2,000 2,000 104,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - - - - -
217 Vitamin B6 10 mg tablet 138.00 - - - - - - - -
218 9,646.00 - - - - - - - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 48 48 48 - 100 - -
OBAT GIZI (DAK 2019) - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - -
221 Hemafort tablet 834.90 - 3,600 3,600 2,000 1,600 7,200 7,200 7,200 6,011,280
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 28 - 28 - 28 - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - Err:522 Err:522 - - -
224 Kapsul 581.00 - - - Err:522 Err:522 - - -
IU
BAHAN MEDIS HABIS PAKAI (DAK ) - Err:522 Err:522
225 Allkohol 70% bottle 28,733.33 - Err:522 Err:522 20 - -
226 Alkohol 70% 1L botol 28,750.00 - Err:522 Err:522 - - -
227 Arm sling L buah 17,424.00 - Err:522 Err:522 - -
228 Arm sling M buah 17,424.00 - Err:522 Err:522 - -
229 Arm sling S buah 17,424.00 - Err:522 Err:522 - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - Err:522 Err:522 24 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 15 15 1 14 - - -
232 Aximed Syringe 1 cc Dus 103,750.00 - Err:522 Err:522 2 2 2 207,500
233 Aximed Syringe 3 cc Dus 103,125.00 2 2 Err:522 Err:522 2 2 2 206,250
234 Blood Lancet box 16,022.60 4 2 6 1 5 5 5 5 80,113

Page 184
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 12 12 - 12 - -
237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 - - - - -
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 24 24 12 12 - -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 24 24 - 24 - - -
240 Catgut chromic 3/0 HR 30 mm Sachet 33,873.38 - Err:522 Err:522 - -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - Err:522 Err:522 - -
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - Err:522 Err:522 - - -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 12 12 Err:522 Err:522 - - -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 24 24 Err:522 Err:522 - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - Err:522 Err:522 - -
251 Chirurgic Gloves, size 7 pcs 9,525.12 - Err:522 Err:522 - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - Err:522 Err:522 - -
253 Chirurgic Gloves, size 8 pcs 9,525.12 - Err:522 Err:522 - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - Err:522 Err:522 - -
255 Dermafix T 10x12cm pcs 6,939.90 50 50 - 50 50 50 50 346,995
256 Examination Gloves size L box 58,564.00 - - - - -
257 Examination Gloves size M box 58,564.00 - - - - 5 5 5 292,820
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 10 10 6 4 5 5 5 187,200
260 Folley catheter 2 way no. 16 pcs 8,800.00 14 14 - 14 - - -
262 Germany Tro-Sensosurge Steril Glove 7.5 pasang 7,254.00 - - - 50 50 50 362,700
263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 97 97 2 95 - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - Err:522 Err:522 - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - Err:522 Err:522 - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - Err:522 Err:522 - -
267 Hb Sahli set 96,800.00 - - Err:522 Err:522 1 1 1 96,800
Page 185
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
268 Hidrogen Peroxide 3% botol 3,864.00 - Err:522 Err:522 - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - Err:522 Err:522 - -
270 Infuset pcs 6,166.16 20 20 20 - 100 50 50 308,308
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - Err:522 Err:522 - -
275 Kapas pembalut 250 gr roll 13,733.33 - Err:522 Err:522 - - -
276 Kapas pembalut 250 gr roll 13,750.00 - Err:522 Err:522 - -
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 5 5 Err:522 Err:522 30 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 - Err:522 Err:522 100 100 100 176,000
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - Err:522 Err:522 - - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - Err:522 Err:522 - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 10 10 2 8 - -
282 Lysol 1 liter botol 47,150.00 7 7 3 1 15 - -
283 Masker Ear Loop Box 20,202.00 5 5 5 - 20 - -
284 Masker Tie on Box 19,869.00 5 5 5 - 20 - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - Err:522 Err:522 - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - Err:522 Err:522 - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - Err:522 Err:522 - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - Err:522 Err:522 - -
289 Onemed Alcohol Swab botol 11,000.00 - Err:522 Err:522 - -
290 Onemed Blood Lancet box 16,022.60 - Err:522 Err:522 - -
291 Onesept 500 ml botol 30,360.00 - Err:522 Err:522 - - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 - Err:522 Err:522 - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 5 5 Err:522 Err:522 - -
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - Err:522 Err:522 - -
295 Safeglove Examination Gloves L box 39,182.00 - Err:522 Err:522 - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - Err:522 Err:522 - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 12 12 - 12 - - -
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - Err:522 Err:522 - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - Err:522 Err:522 - -
Page 186
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
300 Stera Infuset anak pcs 3,850.00 - Err:522 Err:522 - - -
301 Surgical Mask Earloop box 18,150.00 5 5 Err:522 Err:522 - -
302 Surgical Mask Tie On box 18,150.00 5 5 Err:522 Err:522 - -
303 Swab 2 ply dus 14,040.84 - Err:522 Err:522 - -
304 Syringe 10 cc dus 167,266.70 - Err:522 Err:522 - -
305 Syringe 1cc pcs 1,045.80 100 100 - 100 - -
306 Syringe 1cc dus 106,523.56 - Err:522 Err:522 - - -
307 Syringe 3cc dus 107,421.38 - - Err:522 Err:522 200 - -
308 Syringe 5cc dus 119,090.61 - Err:522 Err:522 - - -
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - Err:522 Err:522 - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - Err:522 Err:522 - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - Err:522 Err:522 - -
312 Tp. Disposable Syringe 5 cc pcs 892.78 - Err:522 Err:522 - -

313 pcs 7,072.50 10 10 20 - 20 12 12 12 84,870
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - -
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 - - - - -
318 Urine bag steril (t-valve) pcs 3,300.00 19 19 - 19 - - -
PEMERIKSAAN HIV - - -
319 HIV Device Box 707,143.00 12 12 - 12 - - -
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS - Err:522 Err:522
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - Err:522 Err:522 - -
SUMBER DANA APBD I - Err:522 Err:522
VAKSIN - Err:522 Err:522
321 BCG +Pelarut BCG Vial 61,996.00 - Err:522 Err:522 - -
322 Campak + Pelarut Campak Vial 28,204.00 - Err:522 Err:522 - -
323 DPT-HB-Hib Vial 78,991.00 - Err:522 Err:522 - -
324 DT Vial 17,996.00 - Err:522 Err:522 - -
325 Hepatits B Buah 23,991.00 - Err:522 Err:522 - -
326 IPV Vial 139,760.00 - Err:522 Err:522 - -
327 IPV Vial 144,540.00 - Err:522 Err:522 - -

Page 187
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
328 MR Vial 141,648.00 - Err:522 Err:522 - -
329 Polio+ Dropper Polio Vial 19,954.00 - Err:522 Err:522 - -
330 Td Vial 16,995.00 - Err:522 Err:522 - -
ANTI RABIES - Err:522 Err:522
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - Err:522 Err:522 - -
OBAT FILARIASIS - Err:522 Err:522
332 Albendazol 400 mg tablet 258.74 - Err:522 Err:522 200 - -
OBAT GIZI - Err:522 Err:522
333 Tablet Tambah Darah (Rematri) tablet 372.00 - Err:522 Err:522 1,200 - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - Err:522 Err:522 - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - Err:522 Err:522 - -
OBAT MALARIA - Err:522 Err:522
336 Blood Slide Kotak 18,509.00 5 5 10 5 5 - -
337 DHP Frimal tablet 3,498.00 - Err:522 Err:522 100 - -
338 Kelambu GF Buah 61,077.00 - Err:522 Err:522 - -
339 Primaquin 15 mg tablet 235.00 - Err:522 Err:522 - -
OBAT KIA IBU - Err:522 Err:522
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - Err:522 Err:522 - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - Err:522 Err:522 - - -
342 Euthyrox 50 mcg tablet 735.00 - Err:522 Err:522 - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - Err:522 Err:522 - -
344 Methylergometrin Injeksi ampul 3,102.00 - Err:522 Err:522 - -
345 MgSO4 20 % fls 3,328.00 - Err:522 Err:522 - -
346 MgSO4 40 % fls 3,796.00 - Err:522 Err:522 - -
OBAT KIA ANAK - Err:522 Err:522
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - Err:522 Err:522 - -
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - Err:522 Err:522 - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - Err:522 Err:522 - -
OBAT TB PARU - Err:522 Err:522
350 Box Slide Kotak 41,342.00 - Err:522 Err:522 - -
351 Kaca Slide Kotak 30,000.00 - Err:522 Err:522 - - -
352 Kaca Slide Kotak 20,747.00 - Err:522 Err:522 - -
Page 188
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
353 OAT Kategori Anak Paket 232,518.00 1 1 - 1 - -
354 OAT Kategori I Paket 377,900.00 5 8 13 5 8 - -
355 OAT Kategori II Paket 1,259,990.00 - - 2 2 - -
356 Pot Sputum Pot 2,500.00 1,000 1,000 Err:522 Err:522 - -
357 Reagen Ziehl Neelsen Kit 276,000.00 - Err:522 Err:522 - -
358 Sputum Pot Buah 2,950.00 60 60 60 - - -
359 Tuberkulin Vial 625,900.00 - Err:522 Err:522 - -
KUSTA - Err:522 Err:522
360 MDT PB Dewasa Blister 12,569.00 - Err:522 Err:522 - -
ALAT DETEKSI RESIKO KEHAMILAN - Err:522 Err:522
361 Paket ADRK II Paket 422,980.00 - Err:522 Err:522 - -
IMUNISASI - Err:522 Err:522
362 ADS 0,05 ml Buah 1,518.00 - Err:522 Err:522 - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - Err:522 Err:522 - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - Err:522 Err:522 - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - Err:522 Err:522 - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - Err:522 Err:522 - -
369 ADS 5 ml buah 1,705.00 - Err:522 Err:522 - -
370 ADS 5 ml Buah 1,705.00 - Err:522 Err:522 - -
373 RCW Unit 2,266,454.00 - Err:522 Err:522 - -
374 Safety Box pcs 16,608.00 - Err:522 Err:522 - -
375 Safety Box 2,5 ml Buah 12,500.00 - Err:522 Err:522 - -
376 Safety Box 5 ml Buah 20,394.00 - Err:522 Err:522 - -
377 Vaccine Carrier buah 1,870,000.00 - Err:522 Err:522 - -
OBAT FLU BURUNG - Err:522 Err:522
378 Oseltamivir kapsul 12,969.00 - Err:522 Err:522 - -
OBAT DIARE - Err:522 Err:522
379 Garam Oralit Sachet 257.00 - Err:522 Err:522 - -
Page 189
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
380 Garam Oralit Sachet 253.00 200 100 300 100 200 100 100 100 25,300
381 Zink Tablet tablet 551.00 500 500 500 - - -
OBAT HIV/AIDS - - -
382 Rapid 1 : SD HIV test 11,975.00 100 100 100 - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 50 50 - 50 - -
384 Rapid Sifilis Ab test 20,400.00 - - - - -
385 RPR Sifilis test 4,250.00 25 25 - 25 - -
OBAT HEPATITIS - Err:522 Err:522
386 HB Imuno Globulin Kotak 1,325,000.00 - Err:522 Err:522 - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - Err:522 Err:522 - -
Reagensia/ Alat - Err:522 Err:522
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 200 200 Err:522 Err:522 125 125 125 1,496,875
389 Rapid 2 HIV (Focus) test 13,615.00 - Err:522 Err:522 - -
390 Rapid 2 HIV (KHB) test 12,500.00 - Err:522 Err:522 - -
391 Rapid 3 Diagnostar test 13,771.00 - Err:522 Err:522 - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - Err:522 Err:522 - -
393 Rapid Sifilis Trepocheck test 9,697.00 75 75 - 75 - -
394 RPR Sifilis test 4,250.00 - Err:522 Err:522 - -

SUMBER DANA APBD II - Err:522 Err:522
OBAT KATARAK - Err:522 Err:522
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - Err:522 Err:522 - - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - Err:522 Err:522 - -
OBAT PROGRAM - Err:522 Err:522
397 L- Zinc botol 31,350.00 - Err:522 Err:522 - - -
398 Lagesil Suspensi botol 40,755.00 - - - 30 - -
REAGENTIA - Err:522 Err:522
399 Objek Gelas Kotak 50,000.00 - Err:522 Err:522 - -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - Err:522 Err:522 - -
REAGENSIA - Err:522 Err:522

401 Larutan Alkohol 96% botol 242,000.00 - Err:522 Err:522 - -
402 Larutan Metanol botol 665,500.00 - Err:522 Err:522 - -
403 Reagen Benedict botol 484,000.00 - Err:522 Err:522 - -
404 Reagen Natrium Sitrat botol 514,250.00 - Err:522 Err:522 - -
Page 190
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
405 Reagen Receker botol 2,238,500.00 - Err:522 Err:522 - -
406 Reagensia Asam Asetat botol 544,500.00 - Err:522 Err:522 - -
407 Slide test widal Unit 302,500.00 - Err:522 Err:522 - -
BELANJA STICK NARKOBA - Err:522 Err:522
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - Err:522 Err:522 - -
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - Err:522 Err:522 - -
PENINGKATAN KESEHATAN MASYARAKAT - Err:522 Err:522
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - Err:522 Err:522 - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - Err:522 Err:522 - -

asam askorbat (vitamin C) tablet 110.00 1,000 1,000 600 400 2,000 1,000 1,000 110,000
Alkohol 70% 1L botol 230,000.00 3 3 3 690,000
Alkohol 70% 300 ml botol 80,000.00 22 22 22 1,760,000
hand sanitizer botol 215,000.00 10 10 10 2,150,000
DHP Frimal Tablet 2,134.00 9 9 9 19,206
Masker box 450,000.00 10 10 10 4,500,000
TOTAL 51,743,880

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr. Erliston D.T. Octavian Dina Mulianti
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip.19791019 200604 1 013 Nip.19870128 201001 2 022
Page 191
0
500
1500
0
100
1500
0
0
0
0
900
300
0
0
50
120
3500
20
0
0
4000
Page 192
100
14
0
0
0
0
500
0
0
10
0
50
60
0
72
0
0
0
0
1000
100
0
1000
Page 193
0
0
50
700
100
0
1500
0
50
100
0
0
0
2800
0
60
0
0
0
0
0
700
0
0
0
Page 194
0
0
0
0
0
0
0
30
0
25
200
0
24
2000
200
0
0
0
0
48
0
50
3000
1500
Page 195
1000
0
0
50
1200
1000
0
500
0
0
0
500
0
24
0
50
0
0
1000
0
0
0
500
0
1000
0
1000
2500
0
0
0
Page 196
0
500
10
500
0
0
0
0
0
0
0
0
0
0
0
0
400
0
0
4000
30
0
300
0
3000
2000
0
10
1000
Page 197
0
100
0
0
1000
0
1500
0
500
0
800
0
100
0
0
40
0
1000
0
500
0
5
500
0
0
1680
0
0
0
Page 198
600
100
1000
1000
0
1500
0
0
0
0
0
3600
0
0
0
0
0
0
0
0
2
2
0
Page 199
0
0
0
0
0
0
0
12
0
0
24
0
0
0
0
0
0
0
0
0
0
3
0
10
0
0
0
0
0
0
0
0
Page 200
0
0
20
0
0
0
0
0
0
5
0
0
0
10
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
0
0
0
Page 201
0
5
5
0
0
0
0
0
0
0
0
0
0
10
0
0
0
0
0
0
12
0
0
0
0
0
0
0
0
0
0
0
Page 202
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
0
0
0
0
20
0
0
0
0
0
0
25
0
0
0
0
Page 203
0
0
0
1000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 204
100
500
0
0
0
0
0
0
0
0
0
200
0
0
0
0
75
0
0
0
0
0
0
0
5
0
0
0
0
0
0
0
0
Page 205
0
0
0
0
0
0
0
0
0
0
Page 206
DINKES
PUSKESMAS : GUNTING SAGA LAPORAN TRIWULAN : I (II) III IV GFK 11/IFK/3/2020 10-Sep-20
KECAMATAN : KUALUH HULU PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 2000 - -
200 mg
3 Alopurinol tablet 100 mg tablet 97.00 1900 1500 3400 1,700 1,700 2000 2000 2,000 194,000.00
5 Ambroxol 15 mg/5 ml botol 6,600.00 200 200 100 100 200 200 200 1,320,000.00
6 Ambroxol tab 30 mg tablet 330.00 1600 4000 5600 3,400 2,200 1500 1500 1,500 495,000.00
7 Aminofilin inj 24 mg/ml ampul 2,998.00 120 120 120 - -
8 Aminofilin tablet 200 mg tablet 92.00 200 200 200 - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 3000 3000 2,100 900 1200 - -
11 tablet 78.00 - - 1200 1200 1,200 93,600.00
12 Kaplet 94.00 1350 1350 1,350 - -
13 Amoksisilin 100 mg/mL botol 13,500.00 50 50 50 - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 2000 2000 2,000 - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 200 200 200 150 100 100 660,000.00
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 120 120 120 - -
17 kaptab 261.00 10000 10000 3,400 6,600 10000 10000 10,000 2,610,000.00
20 Antasida Tablet tablet 200.00 3800 4000 7800 7,300 500 - -
21 Antasida Tab Tablet 355.00 6000 6000 6,000 6000 3000 3,000 1,065,000.00
Page 207
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

22 tablet 60.00 - - - -

23 botol 2,189.00 300 300 100 200 200 200 200 437,800.00

+ Polimiksin 10.0003,071.00
IU/g 100 100 100 240 50 50 153,550.00

25 pot 4,540.00 - - -
Asam Salisilat 3%

26 3,325.00 30 30 30 - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 20 20 20 10 10 10 15,400.00
33 Bedak salisil serbuk 2% dus 1,040.00 3 50 53 53 50 - -
34 Bedak Salisil Kotak 8,000.00 - 50 50 50 400,000.00
35 Betametason krim 0,5 mg/g tube 3,388.00 24 12 36 36 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 75 75 75 150 50 50 67,000.00
37 Ampul 130,999.00 1 1 1 5 - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 2 2 2 - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 60 60 120 120 240 120 120 39,240.00
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 168 168 168 60 - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - 72 72 72 225,936.00
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - -
tablet
46 Cetirizin Hydrochloride salut 94.00 2000 2000 2,000 4000 - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - 700 700 700 70,700.00
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 150 150 50 100 200 100 100 297,300.00
Page 208
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 700 700 100 600 - -
tablet
50 salut 165.00 - - -
selaput
51 kapsul 770.00 150 300 450 450 1500 1000 1,000 770,000.00
52 Codeine 10 mg tablet 600.00 100 100 - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 80 100 180 80 100 100 100 100 219,000.00

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 700 1500 2200 2,200 - -
56 tablet 47.00 - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 347 100 447 447 240 240 240 276,480.00
mg/ml
58 Dexamethason inj Ampul 4,500.00 - 30 - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 3500 5000 8500 4,200 4,300 3000 - -
61 Dekstrofen Syrup Botol 11,550.00 - - -
62 Diazepam 2 mg Tablet 86.00 900 900 - - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 10 10 10 10 10 10 18,220.00
65 Diclofenac Sodium 25 mg Tablet 141.00 - - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - 2800 2800 2,800 380,800.00
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 90 90 90 30 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 90 90 90 103,590.00
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - -
70 Digoksin tablet 0,25 mg tablet 106.00 300 300 300 300 - -
71 Digoksin 0,25 mg Tablet 104.00 - 300 300 300 31,200.00
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 1000 1000 1,000 200 - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 100 100 100 50 50 50 139,050.00
Plastik
Page 209
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 3000 3000 2,200 800 3000 - -
75 Domperidon tablet 10 mg tablet 86.00 - 1000 1000 1,000 86,000.00
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 12 12 12 24 24 24 141,600.00
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 - - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 700 500 1200 100 1,100 - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 50 50 100 80 20 50 - -
83 Eugenol cairan botol 21,091.00 1 1 - - -
85 Fenobarbital tablet 30 mg tablet 180.00 - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - -
87 tablet 747.00 - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 500 500 500 - -
89 ampul 3,867.00 30 30 30 30 30 30 116,010.00
mg/ml
90 Fituno Tab tablet 4,163.10 180 180 180 - -
92 Furosemide tablet 40 mg tablet 77.00 2000 2000 2,000 2000 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 10 - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 24 24 24 24 24 24 67,440.00
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 24 24 24 24 24 24 106,848.00
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1700 2000 3700 2,200 1,500 - -
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 20 20 20 - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 600 2000 2600 1,800 800 3000 1000 1,000 245,000.00
99 Griseofulvin tablet 125 mg tablet 232.00 - - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - -
101 Haloperidol 0,5 mg Tablet 55.00 - - -
Page 210
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
103 Hidrokortison krim 2,5 % tube 2,640.00 72 120 192 110 82 120 96 96 253,440.00
104 Hidrokortison krim 2,5% tube 2,475.00 - - -
105 Hustab Syrup botol 11,550.00 300 300 100 200 100 100 100 1,155,000.00
106 Hustab P Tablet 8 mg Tablet 256.67 1500 3000 4500 3,000 1,500 - -
107 Hustab Tablet tablet 437.00 900 3000 3900 1,500 2,400 - -
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - -
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 500 3000 3500 2,500 1,000 2000 - -
selaput
110 Ibuprofen 200 mg Tablet 550.00 - 2000 2000 2,000 1,100,000.00
111 Ibuprofen 400 mg Tablet 800.00 500 3000 3500 3,000 500 2000 500 500 400,000.00
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 100 100 100 100 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - 50 50 50 138,800.00
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 240 240 240 480 - -
116 tablet 63.00 1400 2000 3400 900 2,500 2000 2000 2,000 126,000.00
117 Kanamycin 1 gr inj vial 10,768.00 - - -
118 Kaptopril 12,5 mg tablet 68.00 600 3000 3600 2,400 1,200 2000 1000 1,000 68,000.00
119 Ketokenazol tablet 200 mg tablet 278.00 450 200 650 650 2000 - -
120 Ketokonazol tablet 200 mg tablet 297.00 - - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 - - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - -
123 Kloramfenikol Salep 2% tube 3,349.00 - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 24 24 24 48 24 24 48,168.00
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 50 100 150 150 50 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - 50 50 50 258,400.00
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 7100 7100 7,100 - -
129 Klorfeniramin maleat tablet 25.00 2000 2000 2,000 5000 5000 5,000 125,000.00
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 500 500 500 151,500.00
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 760 760 760 2000 - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 - - -
Page 211
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 2000 2000 1,300 700 1000 700 700 182,000.00
134 Meloksikam 7,5 mg tablet 795.68 - - -
135 Meloxicam tab15 mg tablet 1,438.80 2000 2000 1,000 1,000 1500 700 700 1,007,160.00
136 Meloxicam 15 mg Tablet 980.00 1200 1200 1,200 - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 1000 1000 1,000 3000 - -
138 tablet 137.00 3000 3000 1,000 2,000 3000 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - 3000 3000 3,000 438,000.00
140 Methylprednisolone tablet 4 mg tablet 528.66 - - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 400 500 900 200 700 - -
selaput
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 300 300 300 - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 50 50 20 30 - -
146 Metronidazole tablet 500 mg tablet 264.00 2500 2500 2,000 500 1500 1000 1,000 264,000.00
147 MgSO4 20 % botol 13,500.00 6 6 6 - -
148 MgSO4 40 % botol 13,500.00 6 6 6 - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 24 168 192 132 60 48 48 48 172,080.00
150 NaCl 0,9 % 500 ml botol 6,840.00 60 100 160 140 20 100 100 100 684,000.00
151 tablet 132.00 1600 1600 100 1,500 - -
25 mg
152 tablet 127.00 950 2000 2950 600 2,350 - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 1700 1700 1,000 700 1000 300 300 33,000.00
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 100 100 100 83,000 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - - -
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - -
161 Omeprazol Tab Tablet 650.00 2000 2000 1,700 300 2000 400 400 260,000.00
Page 212
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
163 Paracetamol Tab 500 mg tablet 290.00 - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 8800 10000 18800 12,000 6,800 10400 10400 10,400 1,716,000.00
165 bottle 6,981.00 - - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 200 200 200 236,800 400 - -
167 Pehacain Injeksi ampul 3,113.06 100 100 100 311,306 - -
168 Pehacain Injeksi Ampul 3,113.05 500 500 400 100 200 200 200 622,610.00
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - -
170 Pehastan 500 mg tablet 445.50 2500 2500 2,500 5000 3600 3,600 1,603,800.00
171 Pehavral tablet 935.00 700 2000 2700 2,700 2000 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 24 10 34 34 5 - -
173 Peridol Syrup 60 ml botol 19,800.00 24 24 24 96 - -
174 botol 124,355.00 3 3 3 - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 1000 1000 350 650 1000 1000 1,000 880,000.00
176 tablet 302.00 700 700 700 100 - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 - 100 100 100 32,200.00
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - - -
179 Pirantel Pamoat syrup botol 10,778.00 - - -
180 Tablet 124.00 3000 3000 2,500 500 3000 - -
(HCl)
181 tablet 129.00 - 1500 1500 1,500 193,500.00
(HCl)
182 Prednison tablet 5 mg tablet 76.00 300 1000 1300 1,300 1000 1000 1,000 76,000.00
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 - - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 1650 1000 2650 700 1,950 - -
185 Pyridol Syrup 60 ml botol 18,150.00 - - -
186 Ranitidin 150 mg Tablet tablet 660.00 200 4000 4200 4,200 5000 1300 1,300 858,000.00
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 200 200 500 - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 210 200 410 410 200 200 200 231,000.00
191 Ringer Laktat 500 ml botol 7,630.00 260 200 460 400 60 200 200 200 1,526,000.00
192 Roeko Endo Frost 200 ml botol 352,000.00 - - -
Page 213
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 2000 1000 3000 1,800 1,200 2000 2000 2,000 160,000.00
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 34 34 34 - -
198 pot 2,654.00 24 24 24 - -
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 2000 2000 2,000 3000 500 500 605,000.00
200 Seftriakson serb inj 1.000 mg vial 4,998.00 30 30 10 20 20 20 20 99,960.00
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 300 300 - 1500 - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 1680 1680 1,680 1680 1680 1,680 196,560.00
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 1000 - - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 700 700 300 400 - -
208 tablet 84.00 1500 1500 500 1,000 2000 - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - 500 500 500 43,000.00
tablet
210 salut 93.00 100 100 100 - -
selaput
211 Vapril 25 mg tablet 193.00 1700 3000 4700 4,700 - -
212 box 6,550.00 - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1000 5000 6000 6,000 5000 2500 2,500 307,500.00
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 210 500 710 330 380 500 200 200 227,200.00
215 Vitamin B12 tablet 50 mcg tablet 52.00 2000 2000 1600 400 3000 3000 3,000 156,000.00
218 9,646.00 20 20 20 10 - -
plabot Plastik
Page 214
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 1300 700 2000 2,000 2000 - -
221 Hemafort tablet 834.90 - 3600 3600 3,600 3,005,640.00
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 40 40 - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - -
224 Kapsul 581.00 - - -
IU
BAHAN MEDIS HABIS PAKAI (DAK ) - - -
225 Allkohol 70% bottle 28,733.33 - - -
226 Alkohol 70% 1L botol 28,750.00 - - -
227 Arm sling L buah 17,424.00 - - - -
228 Arm sling M buah 17,424.00 - -
229 Arm sling S buah 17,424.00 - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - -
233 Aximed Syringe 3 cc Dus 103,125.00 10 10 10 10 10 10 1,031,250.00
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 24 24 24 48 48 48 1,668,960.00
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 48 48 48 48 24 24 834,480.00
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - -
Page 215
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 20 20 20 103,960.00
255 Dermafix T 10x12cm pcs 6,939.90 - -
256 Examination Gloves size L box 58,564.00 5 5 5 20 5 5 292,820.00
257 Examination Gloves size M box 58,564.00 10 10 10 20 9 9 527,076.00
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 5 5 5 20 10 10 374,400.00
260 Folley catheter 2 way no. 16 pcs 8,800.00 - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 50 50 50 50 50 50 362,700.00
262 Germany Tro-Sensosurge Steril Glove 7.5 pasang 7,254.00 50 50 50 50 50 50 362,700.00
263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 - - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - - -
267 Hb Sahli set 96,800.00 - - -
268 Hidrogen Peroxide 3% botol 3,864.00 - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - -
270 Infuset pcs 6,166.16 - - -
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - -
Page 216
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
278 Kasa kompres steril 40 x 40 pcs 1,760.00 - -
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - -
284 Masker Tie on Box 19,869.00 20 - -
289 Onemed Alcohol Swab botol 11,000.00 - - - -
290 Onemed Blood Lancet box 16,022.60 - - 10 10 10 160,226.00
291 Onesept 500 ml botol 30,360.00 - - - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - - -
301 Surgical Mask Earloop box 18,150.00 - -
303 Swab 2 ply dus 14,040.84 - -
304 Syringe 10 cc dus 167,266.70 - -
305 Syringe 1cc pcs 1,045.80 - -
306 Syringe 1cc dus 106,523.56 - -
307 Syringe 3cc dus 107,421.38 - - - -
Page 217
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
308 Syringe 5cc dus 119,090.61 - - - -

313 pcs 7,072.50 - - - -
Airvent, Luer Lock
318 Urine bag steril (t-valve) pcs 3,300.00 - -
PEMERIKSAAN HIV - -
319 HIV Device Box 707,143.00 20 20 - -
VAKSIN - -
323 DPT-HB-Hib Vial 78,991.00 - -
324 DT Vial 17,996.00 - -
325 Hepatits B Buah 23,991.00 - -
326 IPV Vial 139,760.00 - -
327 IPV Vial 144,540.00 - -
328 MR Vial 141,648.00 - -
330 Td Vial 16,995.00 - -
ANTI RABIES - - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - -
Page 218
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT FILARIASIS - - -
332 Albendazol 400 mg tablet 258.74 - -
OBAT GIZI - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - -
OBAT MALARIA - -
336 Blood Slide Kotak 18,509.00 6 6 - -
338 Kelambu GF Buah 61,077.00 - -
339 Primaquin 15 mg tablet 235.00 100 100 100 23,500.00
OBAT KIA IBU - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - - - -
344 Methylergometrin Injeksi ampul 3,102.00 - - - -
345 MgSO4 20 % fls 3,328.00 - - - -
346 MgSO4 40 % fls 3,796.00 - - - -
OBAT KIA ANAK - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - - - -
OBAT TB PARU - -
350 Box Slide Kotak 41,342.00 - - - -
351 Kaca Slide Kotak 30,000.00 - - - -
352 Kaca Slide Kotak 20,747.00 - - - -
Page 219
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
356 Pot Sputum Pot 2,500.00 1800 1800 - - - -
KUSTA - -
ALAT DETEKSI RESIKO KEHAMILAN - -
IMUNISASI - -
362 ADS 0,05 ml Buah 1,518.00 - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - -
364 ADS 0,5 ml Buah 1,127.00 - -
365 ADS 0,5 ml Buah 1,090.00 - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 5 5 - -
369 ADS 5 ml buah 1,705.00 - -
370 ADS 5 ml Buah 1,705.00 - -
371 ADS 5 ml Buah 1,439.00 - -
372 ADS 5 ml Buah 1,500.00 - -
373 RCW Unit 2,266,454.00 - -
374 Safety Box pcs 16,608.00 - -
376 Safety Box 5 ml Buah 20,394.00 75 75 - - - -
OBAT FLU BURUNG - -
OBAT DIARE - - -
379 Garam Oralit Sachet 257.00 100 100 100 1,000 - -
380 Garam Oralit Sachet 253.00 1500 1500 1,500 - 1,000 500 500 126,500.00
Page 220
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
381 Zink Tablet tablet 551.00 - - -
OBAT HIV/AIDS - -
382 Rapid 1 : SD HIV test 11,975.00 300 300 - - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - -
385 RPR Sifilis test 4,250.00 - - - -
OBAT HEPATITIS - - -
Reagensia/ Alat - - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - -
390 Rapid 2 HIV (KHB) test 12,500.00 - - -
391 Rapid 3 Diagnostar test 13,771.00 - - -
393 Rapid Sifilis Trepocheck test 9,697.00 100 100 - - -
394 RPR Sifilis test 4,250.00 - - -
SUMBER DANA APBD II - -
OBAT KATARAK - -
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 5 - -
OBAT PROGRAM - -
397 L- Zinc botol 31,350.00 50 - -
398 Lagesil Suspensi botol 40,755.00 20 20 40 - -
REAGENTIA - -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - -
REAGENSIA - - -
401 Larutan Alkohol 96% botol 242,000.00 - - -
402 Larutan Metanol botol 665,500.00 - - -
Page 221
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
406 Reagensia Asam Asetat botol 544,500.00 - - -
407 Slide test widal Unit 302,500.00 - - -
BELANJA STICK NARKOBA - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - -
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - -
PENINGKATAN KESEHATAN MASYARAKAT - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 10 - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 10 - -
fokus diagnostic sypilis Test - -
fokus New HIV1/2 Test - -
DHP Frimal Tablet 2,134.00 9 9 - -
Lysol 1 liter botol 82,150.00 10 10 40 40 40 3,286,000.00
povidon iodine60 ml botol 5,186.50 20 20 20 103,730.00
Alkohol 70% 1L botol 230,000.00 10 10 20 10 10 2,300,000.00
Alkohol 70% 300 ml botol 80,000.00 - -
hand sanitizer botol 215,000.00 10 10 - -
Clobazam 10 mg tablet 776.00 100 100 100 77,600.00
Clozapim 25 mg tablet 1,121.00 100 100 100 112,100.00
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1000 1000 1,000 110,000.00
Masker box 450,000.00 20 20 20 9,000,000.00

TOTAL 51,226,384

Page 222
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr. Parianti Lubis Leonardo Arvince Guru Singa
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip.19790731 201101 2 006 NIP. 198402152010011033
Page 223
DINKES
PUSKESMAS : SONOMARTANI LAPORAN TRIWULAN : I (II) III IV GFK 10/IFK/3/2020 4-Sep-20
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 1000 1000 1000 500 - -
200 mg
4 Alopurinol tablet 100 mg tablet 104.00 1300 1300 100 1200 - -
5 Ambroxol 15 mg/5 ml botol 6,600.00 43 50 93 3 90 100 100 100 660,000
6 Ambroxol tab 30 mg tablet 330.00 2000 2000 200 1800 - -
7 Aminofilin inj 24 mg/ml ampul 2,998.00 5 5 5 - -
8 Aminofilin tablet 200 mg tablet 92.00 200 200 100 100 - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 900 900 900 - -
11 tablet 78.00 - -
12 Kaplet 94.00 - -
13 Amoksisilin 100 mg/mL botol 13,500.00 20 20 20 - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 - -
17 kaptab 261.00 2000 2000 2000 1000 1000 1,000 261,000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - -
19 Antasida Tablet box 5,594.00 - -
Page 224
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
20 Antasida Tablet tablet 200.00 1000 1000 1000 - -
21 Antasida Tab Tablet 355.00 1000 1000 300 700 1000 1000 1,000 355,000

22 tablet 60.00 - -

23 botol 2,189.00 165 165 160 50 50 50 109,450

+ Polimiksin 10.000
3,071.00
IU/g 16 25 41 36 25 25 25 76,775

25 pot 4,540.00 8 24 32 27 - -
Asam Salisilat 3%

26 3,325.00 10 10 10 - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - -
28 Asam Mefenamat 500 mg tablet 242.89 - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - -
31 Asiklovir Tablet 200 mg Tablet 560.18 300 300 50 250 - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - -
33 Bedak salisil serbuk 2% dus 1,040.00 13 90 103 2 101 20 - -
34 Bedak Salisil Kotak 8,000.00 20 20 20 160,000
35 Betametason krim 0,5 mg/g tube 3,388.00 52 52 52 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - -
37 Ampul 130,999.00 - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 130 130 130 24 - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 48 48 48 150,624
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 380 380 80 300 - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 3 3 3 - -
Page 225
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
46 Cetirizin Hydrochloride salut 94.00 - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 1000 1000 200 800 1000 700 700 70,700
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 100 100 100 297,300
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 700 700 700 500 - -
tablet
50 salut 165.00 - -
selaput
51 kapsul 770.00 1300 1300 1300 500 500 500 385,000
52 Codeine 10 mg tablet 600.00 80 80 80 - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 90 90 40 50 - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 50 50 50 109,500

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 500 500 500 500 1000 - -
56 tablet 47.00 - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 80 80 80 - -
mg/ml
58 Dexamethason inj Ampul 4,500.00 - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 2700 2700 2300 400 1000 - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - -
61 Dekstrofen Syrup Botol 11,550.00 81 50 131 19 112 - -
62 Diazepam 2 mg Tablet 86.00 100 100 100 - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 - -
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 59 59 59 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 30 30 30 34,530
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - -
Page 226
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
70 Digoksin tablet 0,25 mg tablet 106.00 100 100 100 - -
71 Digoksin 0,25 mg Tablet 104.00 - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 480 480 480 500 - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 43 43 43 50 50 50 139,050
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 500 500 500 500 - -
75 Domperidon tablet 10 mg tablet 86.00 200 200 100 100 500 500 500 43,000
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 6 6 6 - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 5 5 5 - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 180 180 180 - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 38 38 38 - -
83 Eugenol cairan botol 21,091.00 5 5 5 - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - -
87 tablet 747.00 300 300 10 290 300 - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 300 300 300 239,100
89 ampul 3,867.00 59 59 31 28 30 - -
mg/ml
90 Fituno Tab tablet 4,163.10 90 300 390 60 330 500 120 120 499,572
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - -
92 Furosemide tablet 40 mg tablet 77.00 500 500 500 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 10 10 10 - -
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 10 10 10 - -
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1200 1200 1200 - -
Page 227
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 12 20 32 12 20 20 - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 - -
99 Griseofulvin tablet 125 mg tablet 232.00 - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - -
101 Haloperidol 0,5 mg Tablet 55.00 - -
103 Hidrokortison krim 2,5 % tube 2,640.00 101 101 9 92 - -
104 Hidrokortison krim 2,5% tube 2,475.00 - -
105 Hustab Syrup botol 11,550.00 108 108 16 92 - -
106 Hustab P Tablet 8 mg Tablet 256.67 300 300 300 900 900 900 231,003
107 Hustab Tablet tablet 437.00 - -
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 2400 2400 2400 500 500
selaput
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 30 30 30 20 - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 50 50 50 138,800
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 100 100 100 - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 240 240 90 150 1000 - -
116 tablet 63.00 1000 1000 100 900 - -
117 Kanamycin 1 gr inj vial 10,768.00 - -
118 Kaptopril 12,5 mg tablet 68.00 970 970 70 900 - -
119 Ketokenazol tablet 200 mg tablet 278.00 250 250 130 200 200 - -
120 Ketokonazol tablet 200 mg tablet 297.00 300 300 300 - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 200 200 200 132,000
123 Kloramfenikol Salep 2% tube 3,349.00 - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 99 99 99 - -
Page 228
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - -
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 700 700 400 - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - -
129 Klorfeniramin maleat tablet 25.00 1000 1000 500 500 1000 1000 1,000 25,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - -
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 100 100 100 - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 500 500 200 300 500 500 500 130,000
134 Meloksikam 7,5 mg tablet 795.68 - -
135 Meloxicam tab15 mg tablet 1,438.80 1700 1700 1700 1000 700 700 1,007,160
136 Meloxicam 15 mg Tablet 980.00 - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 500 500 200 300 200 - -
138 tablet 137.00 500 500 500 500 1000 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 500 500 500 1000 1000 1,000 146,000
140 Methylprednisolone tablet 4 mg tablet 528.66 - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 300 300 300 200 200 200 44,400
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 20 20 20 - -
146 Metronidazole tablet 500 mg tablet 264.00 800 800 200 600 500 500 500 132,000
147 MgSO4 20 % botol 13,500.00 3 3 3 - -
148 MgSO4 40 % botol 13,500.00 3 3 3 - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 30 30 15 15 50 48 48 172,080
150 NaCl 0,9 % 500 ml botol 6,840.00 95 95 8 87 - -
151 tablet 132.00 1150 1150 150 1000 - -
25 mg
152 tablet 127.00 800 800 100 700 - -
50 mg
Page 229
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 2000 2000 2000 - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 500 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 200 200 200 177,200
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 40 40 40 50 - -
161 Omeprazol Tab Tablet 650.00 840 840 840 - -
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 10 10 10 - -
163 Paracetamol Tab 500 mg tablet 290.00 - -
164 Paracetamol kaplet 500 mg kaplet 165.00 500 3000 3500 1500 2000 1000 1000 1,000 165,000
165 bottle 6,981.00 28 28 1 27 - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 44 44 44 50 - -
167 Pehacain Injeksi ampul 3,113.06 - -
168 Pehacain Injeksi Ampul 3,113.05 76 76 76 100 100 100 311,305
169 Pehamoksil Tablet 500 mg Tablet 759.00 750 750 750 - -
170 Pehastan 500 mg tablet 445.50 1280 1000 2280 2280 2000 2000 2,000 891,000
171 Pehavral tablet 935.00 100 2000 2100 1200 900 1000 200 200 187,000
172 Perak sulfadiazin krim 1% tube 20,700.00 21 21 21 5 - -
173 Peridol Syrup 60 ml botol 19,800.00 24 24 24 - -
174 botol 124,355.00 - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 100 100 100 - -
176 tablet 302.00 900 900 900 - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 100 100 100 300 200 200 64,400
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 34 34 34 50 - -
179 Pirantel Pamoat syrup botol 10,778.00 10 10 10 107,780
180 Tablet 124.00 1400 1400 1300 100 - -
(HCl)
181 tablet 129.00 300 500 800 800 1000 1000 1,000 129,000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 500 500 500 38,000
Page 230
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 1400 1400 1400 500 - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 900 900 900 - -
185 Pyridol Syrup 60 ml botol 18,150.00 80 80 5 75 - -
186 Ranitidin 150 mg Tablet tablet 660.00 2200 2200 1700 500 2000 1500 1,500 990,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 85 85 85 50 - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 80 80 80 92,400
191 Ringer Laktat 500 ml botol 7,630.00 61 61 17 44 60 60 60 457,800
192 Roeko Endo Frost 200 ml botol 352,000.00 - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 500 500 500 - -
194 Salbutamol 2 mg tab tablet 67.00 - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1300 1300 100 1200 - -
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - -
198 pot 2,654.00 24 24 24 - -
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - -
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 69 69 69 20 - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 1260 1260 30 1230 510 510 510 56,100
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 120 120 120 - -
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 500 500 500 - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 5 5 5 - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 - -
208 tablet 84.00 1000 1000 100 900 500 - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 500 500 500 43,000
tablet
210 salut 93.00 100 100 100 - -
selaput
Page 231
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
211 Vapril 25 mg tablet 193.00 100 100 100 - -
212 box 6,550.00 - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1200 1200 300 900 1000 1000 1,000 123,000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 90 90 90 500 100 100 113,600
215 Vitamin B12 tablet 50 mcg tablet 52.00 1000 500 1500 300 1200 500 500 500 26,000
218 9,646.00 - -
plabot Plastik
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 10800 16800 27600 10800 16800 - -
221 Hemafort tablet 834.90 800 800 100 700 500 500 500 417,450
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 40 40 40 - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 100 100 100 100 100 100 32,400
224 Kapsul 581.00 100 100 100 - -
IU
225 Allkohol 70% bottle 28,733.33 9 9 3 6 - -
226 Alkohol 70% 1L botol 28,750.00 1 1 1 5 - -
227 Arm sling L buah 17,424.00 - -
228 Arm sling M buah 17,424.00 - -
229 Arm sling S buah 17,424.00 - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - -
233 Aximed Syringe 3 cc Dus 103,125.00 680 680 280 400 - -
Page 232
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 36 36 36 1,308,240
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 12 12 12 496,380
245 Catgut Plain 3/0 DS 19 mm Sachet 40,137.40 50 - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 27 27 27 - -
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 17 20 37 17 20 - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 20 20 20 - -
255 Dermafix T 10x12cm pcs 6,939.90 10 10 10 - -
256 Examination Gloves size L box 58,564.00 3 3 3 175,692
257 Examination Gloves size M box 58,564.00 - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 6 6 6 - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - -
Page 233
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
266 Gynaecologycal Glove, Small pcs 40,733.00 - -
267 Hb Sahli set 96,800.00 - -
268 Hidrogen Peroxide 3% botol 3,864.00 - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 8 10 18 10 8 - -
270 Infuset pcs 6,166.16 15 20 35 19 16 50 50 50 308,308
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 20 20 20 - -
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 20 20 20 - -
275 Kapas pembalut 250 gr roll 13,733.33 6 6 2 4 10 - -
276 Kapas pembalut 250 gr roll 13,750.00 10 10 10 137,500
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 20 20 20 50 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 90 100 190 110 80 100 100 100 176,000
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 50 50 50 - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 50 50 10 40 - -
284 Masker Tie on Box 19,869.00 - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - -
289 Onemed Alcohol Swab botol 11,000.00 - -
290 Onemed Blood Lancet box 16,022.60 - -
291 Onesept 500 ml botol 30,360.00 - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 4 4 4 - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - -
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 12 12 12 - -
Page 234
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
295 Safeglove Examination Gloves L box 39,182.00 - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 2 2 2 - -
301 Surgical Mask Earloop box 18,150.00 - -
303 Swab 2 ply dus 14,040.84 - -
304 Syringe 10 cc dus 167,266.70 - -
305 Syringe 1cc pcs 1,045.80 - -
306 Syringe 1cc dus 106,523.56 - -
307 Syringe 3cc dus 107,421.38 - -
308 Syringe 5cc dus 119,090.61 - -
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - -

313 pcs 7,072.50 20 20 4 16 20 20 20 141,450
Airvent, Luer Lock
318 Urine bag steril (t-valve) pcs 3,300.00 9 9 9 - -
PEMERIKSAAN HIV
319 HIV Device Box 707,143.00 14 14 14 - -
Page 235
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
SUMBER DANA APBD I
VAKSIN
323 DPT-HB-Hib Vial 78,991.00 - -
324 DT Vial 17,996.00 - -
325 Hepatits B Buah 23,991.00 - -
326 IPV Vial 139,760.00 - -
327 IPV Vial 144,540.00 - -
328 MR Vial 141,648.00 - -
330 Td Vial 16,995.00 - -
ANTI RABIES
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - -
OBAT FILARIASIS
332 Albendazol 400 mg tablet 258.74 6000 6000 6000 - -
OBAT GIZI
333 Tablet Tambah Darah (Rematri) tablet 372.00 20000 20000 20000 - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 2 - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 100 100 100 2 - -
OBAT MALARIA
336 Blood Slide Kotak 18,509.00 5 5 2 3 3 - -
338 Kelambu GF Buah 61,077.00 - -
339 Primaquin 15 mg tablet 235.00 - -
OBAT KIA IBU
341 Ca. Glukonas Injeksi ampul 10,351.00 - -
Page 236
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 20 20 20 - -
345 MgSO4 20 % fls 3,328.00 12 12 12 - -
346 MgSO4 40 % fls 3,796.00 12 12 12 - -
OBAT KIA ANAK
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 25 50 50 - -
OBAT TB PARU
350 Box Slide Kotak 41,342.00 - -
356 Pot Sputum Pot 2,500.00 400 1000 1400 100 1300 - -
KUSTA
IMUNISASI
362 ADS 0,05 ml Buah 1,518.00 - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - -
364 ADS 0,5 ml Buah 1,127.00 - -
365 ADS 0,5 ml Buah 1,090.00 - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - -
Page 237
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
367 ADS 0,5 ml SKIFA buah 1,240.00 - -
369 ADS 5 ml buah 1,705.00 - -
370 ADS 5 ml Buah 1,705.00 - -
371 ADS 5 ml Buah 1,439.00 - -
372 ADS 5 ml Buah 1,500.00 - -
373 RCW Unit 2,266,454.00 - -
374 Safety Box pcs 16,608.00 - -
OBAT FLU BURUNG
OBAT DIARE
381 Zink Tablet tablet 551.00 600 600 100 500 - -
OBAT HIV/AIDS
382 Rapid 1 : SD HIV test 11,975.00 - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 25 25 25 - -
OBAT HEPATITIS
Reagensia/ Alat
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 300 300 300 - -
Page 238
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
393 Rapid Sifilis Trepocheck test 9,697.00 50 50 50 - -
SUMBER DANA APBD II
OBAT KATARAK
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - -
OBAT PROGRAM
397 L- Zinc botol 31,350.00 12 12 12 50 - -
398 Lagesil Suspensi botol 40,755.00 - -
REAGENTIA
REAGENSIA
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 1 1 - -
fokus diagnostic sypilis Test 50 50 50 - -
Page 239
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
fokus New HIV1/2 Test 50 50 50 - -
DHP Frimal Tablet 2,134.00 9 9 9 - -
Lysol 1 liter botol 82,150.00 10 10 2 8 40 40 40 3,286,000
povidon iodine60 ml botol 5,186.50 24 24 15 9 30 20 20 103,730
Alkohol 70% 1L botol 2 2 2 5 5 5 -
Alkohol 70% 300 ml botol 80,000.00 5 5 5 - -
hand sanitizer botol 215,000.00 5 5 3 2 50 2 2 430,000
Clobazam 10 mg tablet 776.00 300 300 30 - -
Clozapim 25 mg tablet 1,121.00 300 300 300 - -
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1000 1000 1,000 110,000
Masker box 450,000.00 5 5 5 2,250,000
TOTAL 19,790,209

Kepala Dinas Kesehatan Kabid. Sumber Daya Kesehatan Kasie Farmasi Kepala Puskesmas Sonomartani Pengelola obat
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr.Jefri T.U Simarmata Junita Duma Minarni Sitorus
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip. 198509292017041001 Nip. 197506072014082002
Page 240
DINKES
PUSKESMAS : KAMPUNG PAJAK LAPORAN TRIWULAN : I (II) III IV GFK 9/IFK/3/2020 31-Aug-20
KECAMATAN : NA. IX-X PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule - - -
200 mg
3 Alopurinol tablet 100 mg tablet 97.00 - 1,000 1,000 400 600 2,000 2,000 2,000 194,000.00
5 Ambroxol 15 mg/5 ml botol 6,600.00 50 50 15 35 100 200 200 1,320,000.00
6 Ambroxol tab 30 mg tablet 330.00 200 1,000 1,200 700 500 2,000 2,000 2,000 660,000.00
7 Aminofilin inj 24 mg/ml ampul 2,998.00 60 60 - 60 - -
8 Aminofilin tablet 200 mg tablet 92.00 200 200 200 - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 - - - -
11 tablet 78.00 170 600 770 280 490 2,100 2,100 2,100 163,800.00
12 Kaplet 94.00 300 300 70 230 1,200 1,200 1,200 112,800.00
14 Amoksisilin 250 mg kapsul Kapsul 203.00 500 1,500 2,000 1,800 200 2,000 2,000 2,000 406,000.00
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 - - - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 100 100 64 36 150 120 120 440,400.00
17 kaptab 261.00 300 3,000 3,300 1,800 1,500 5,000 5,000 5,000 1,305,000.00
20 Antasida Tablet tablet 200.00 - - - -
21 Antasida Tab Tablet 355.00 2,000 2,000 1,600 400 4,000 4,000 4,000 1,420,000.00
Page 241
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
22 tablet 60.00 - - - -
23 botol 2,189.00 - - 100 100 100 218,900.00

+ Polimiksin 10.0003,071.00
IU/g 60 60 12 48 24 - -

25 pot 4,540.00 24 24 48 29 19 72 72 72 326,880.00
Asam Salisilat 3%
Antihemoroid, Kombinasi sup: bismut subgalat suppositori

26 3,325.00 - - - -
heksaklorofen a
27 Arkine 100 tablet 687.50 - - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 500 500 20 480 1,000 700 700 171,500.00
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - - - -
33 Bedak salisil serbuk 2% dus 1,040.00 - - - -
34 Bedak Salisil Kotak 8,000.00 - - - -
35 Betametason krim 0,5 mg/g tube 3,388.00 - - - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - - -
37 Ampul 130,999.00 - - - -
(i.m)
kaptab
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 - - - -

41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - 48 48 48 150,624.00
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - -
tablet salut
46 Cetirizin Hydrochloride 94.00 - - - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 700 700 700 - 3,000 300 300 30,300.00
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 50 50 24 26 100 100 100 297,300.00
Page 242
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - -
Chlorpromazine hydrochloride/ Chlorpromazine tablet salut

50 165.00 - - 200 200 200 33,000.00
/Klorpromazin tablet/kaplet salut selaput 100 mg selaput

51 kapsul 770.00 - - 500 500 500 385,000.00
52 Codeine 10 mg tablet 600.00 500 500 200 300 200 100 100 60,000.00
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 40 40 18 22 50 50 50 109,500.00

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 1,500 1,500 720 780 2,000 1,000 1,000 133,000.00
56 tablet 47.00 - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 385 100 485 458 27 100 - -
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - 100 100 100 450,000.00

59 Dexametason Tablet 0,5 mg Tablet 33.00 6,000 6,000 5,500 500 4,000 4,000 4,000 132,000.00
62 Diazepam 2 mg Tablet 86.00 - - - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 10 10 10 - -
65 Diclofenac Sodium 25 mg Tablet 141.00 - - - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - - - 2,800 2,800 2,800 380,800.00
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 300 300 300 300 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - - 300 300 300 345,300.00
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - -
71 Digoksin 0,25 mg Tablet 104.00 - - 1,000 1,000 1,000 104,000.00
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 - - - -
Plastik
Page 243
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
75 Domperidon tablet 10 mg tablet 86.00 1,000 1,000 420 580 2,000 1,000 1,000 86,000.00
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 - - - -
selaput
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 180 180 180 - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - -
87 tablet 747.00 - - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 100 100 40 60 1,000 500 500 398,500.00
89 ampul 3,867.00 70 90 160 56 104 50 - -
mg/ml
92 Furosemide tablet 40 mg tablet 77.00 200 200 30 170 1,000 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 10 10 10 - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 7 7 7 - -
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 7 7 7 - -
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 400 1,000 1,400 600 800 1,000 1,000 1,000 125,000.00
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 20 20 20 - 20 20 20 147,260.00
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 500 500 500 - 1,000 1,000 1,000 245,000.00
99 Griseofulvin tablet 125 mg tablet 232.00 1,000 500 1,500 800 700 1,000 - -
101 Haloperidol 0,5 mg Tablet 55.00 - - - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - -
Page 244
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
105 Hustab Syrup botol 11,550.00 32 50 82 60 22 50 50 50 577,500.00
106 Hustab P Tablet 8 mg Tablet 256.67 300 300 300 - 900 900 900 231,003.00
107 Hustab Tablet tablet 437.00 270 300 570 570 3,600 3,600 3,600 1,573,200.00
tablet salut
108 Ibuprofen tab/kaps/kapl 200 mg 108.00 2,000 2,000 800 1,200 2,000 - -
selaput
tablet salut
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg 105.00 - - - -
selaput
110 Ibuprofen 200 mg Tablet 550.00 800 800 400 400 1,000 1,000 1,000 550,000.00
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 - - - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 660 660 580 80 1,000 - -
116 tablet 63.00 700 1,000 1,700 800 900 1,500 1,500 1,500 94,500.00
118 Kaptopril 12,5 mg tablet 68.00 300 1,000 1,300 800 500 1,000 1,000 1,000 68,000.00
119 Ketokenazol tablet 200 mg tablet 278.00 - - - -
120 Ketokonazol tablet 200 mg tablet 297.00 300 300 120 180 500 - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 200 200 200 - - - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 1,000 1,000 500 500 2,000 700 700 462,000.00
124 Kloramfenikol salep mata 1 % Tube 2,007.00 48 48 2 46 - -
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 50 50 50 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - - -
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 4,100 4,100 3,500 600 4,000 - -
129 Klorfeniramin maleat tablet 25.00 - - 4,000 4,000 4,000 100,000.00
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 1,000 1,000 440 560 1,000 700 700 212,100.00
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 300 300 300 - - -
Page 245
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 200 500 700 400 300 1,000 300 300 78,000.00
134 Meloksikam 7,5 mg tablet 795.68 - - - -
135 Meloxicam tab15 mg tablet 1,438.80 100 200 300 300 2,000 2,000 2,000 2,877,600.00
Metformin Hydrochloride/ Metformin
tablet salut
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan 106.00 200 500 700 500 200 1,000 - -
selaput
strip/blister (G)
138 tablet 137.00 400 2,000 2,400 1,600 800 2,000 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - - 2,000 2,000 2,000 292,000.00

tablet salut
142 Metil Ergometrin tablet Salut Selaput 0,125 mg 222.00 1,000 1,000 400 600 - -
selaput
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 - - - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - - - -
146 Metronidazole tablet 500 mg tablet 264.00 200 1,000 1,200 900 300 2,000 700 700 184,800.00
147 MgSO4 20 % botol 13,500.00 - - - -
148 MgSO4 40 % botol 13,500.00 - - - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 30 48 78 36 42 48 48 48 172,080.00
150 NaCl 0,9 % 500 ml botol 6,840.00 - - - -
151 tablet 132.00 - - - -
25 mg
152 tablet 127.00 750 4,800 5,550 2,050 3,500 2,000 - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 500 500 1,000 700 300 1,000 200 200 22,000.00
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 - - - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - - - -
Page 246
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
161 Omeprazol Tab Tablet 650.00 - - 2,000 400 400 260,000.00
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 10 10 10 - -
164 Paracetamol kaplet 500 mg kaplet 165.00 3,000 3,000 2,800 200 5,200 5,200 5,200 858,000.00
165 bottle 6,981.00 - - 30 - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - - 100 - -
167 Pehacain Injeksi ampul 3,113.06 - - - -
168 Pehacain Injeksi Ampul 3,113.05 15 2,000 2,015 135 1,880 - -
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - -
170 Pehastan 500 mg tablet 445.50 3,000 3,000 3,000 - 4,000 2,500 2,500 1,113,750.00
171 Pehavral tablet 935.00 300 1,000 1,300 720 580 1,000 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 - - - -
173 Peridol Syrup 60 ml botol 19,800.00 - - - -
174 botol 124,355.00 - - - -
0,2 %
175 Phaproxin 500 mg tablet 880.00 - - 200 200 200 176,000.00
176 tablet 302.00 - - - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 300 300 100 200 500 300 300 96,600.00
180 Tablet 124.00 - - - -
(HCl)
181 tablet 129.00 400 500 900 800 100 2,000 2,000 2,000 258,000.00
(HCl)
182 Prednison tablet 5 mg tablet 76.00 - - 2,000 2,000 2,000 152,000.00
184 Pularex Attapulgit tab 630 mg tablet 142.00 850 500 1,350 750 600 500 200 200 28,400.00
185 Pyridol Syrup 60 ml botol 18,150.00 - - - -
186 Ranitidin 150 mg Tablet tablet 660.00 2,000 2,000 1,400 600 3,000 800 800 528,000.00
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - - -
191 Ringer Laktat 500 ml botol 7,630.00 20 20 20 - 20 20 20 152,600.00
Page 247
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 - - - -
198 pot 2,654.00 - - 72 72 72 191,088.00
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - - - -
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - - - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 660 1,680 2,340 1,650 690 1,680 1,680 1,680 196,560.00
tablet salut
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg 214.00 - - - - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - - - -

206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 - - - - -
208 tablet 84.00 - - - 1,000 - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - - - 1,000 1,000 1,000 86,000.00

210 93.00 100 100 200 200 - -
211 Vapril 25 mg tablet 193.00 - - - -

212 box 6,550.00 - - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,000 1,000 320 680 1,000 700 700 86,100.00
215 Vitamin B12 tablet 50 mcg tablet 52.00 300 1,000 1,300 700 600 3,000 3,000 3,000 156,000.00
218 9,646.00 - - - -
plabot Plastik
Page 248
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 25,000 56,000 81,000 20,000 61,000 - -
221 Hemafort tablet 834.90 1,200 2,000 3,200 3,200 7,200 7,200 7,200 6,011,280.00

222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 40 40 40 - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 100 100 100 - - -
224 Kapsul 581.00 100 100 100 - - -
IU
225 Allkohol 70% bottle 28,733.33 - - - -
226 Alkohol 70% 1L botol 28,750.00 - - - -
227 Arm sling L buah 17,424.00 - - - -
228 Arm sling M buah 17,424.00 - - - -
229 Arm sling S buah 17,424.00 - - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 17 17 9 8 - -
232 Aximed Syringe 1 cc Dus 103,750.00 - - 2 2 2 207,500.00
233 Aximed Syringe 3 cc Dus 103,125.00 5 5 4 1 6 5 5 515,625.00
234 Blood Lancet box 16,022.60 - - - -
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 51 48 99 29 70 48 24 24 1,023,960.00
Page 249
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - 20 20 20 252,620.00
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - - 40 40 40 505,240.00
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 40 40 26 14 40 30 30 378,930.00
255 Dermafix T 10x12cm pcs 6,939.90 - - - -
256 Examination Gloves size L box 58,564.00 - - - -
257 Examination Gloves size M box 58,564.00 - - - -
267 Hb Sahli set 96,800.00 - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - -
270 Infuset pcs 6,166.16 - - - -
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 20 20 2 18 20 20 20 163,301.60
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 36 36 12 24 40 40 40 323,554.00
273 IV- Cath WP, with wings & port no 24 pcs 8,088.85 - - 30 30 30 242,665.50
Page 250
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
276 Kapas pembalut 250 gr roll 13,750.00 - - 10 10 10 137,500.00
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 52 - 52 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 100 100 100 100 100 100 176,000.00
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - - - -
282 Lysol 1 liter botol 47,150.00 - - - -
284 Masker Tie on Box 19,869.00 - - - -
290 Onemed Blood Lancet box 16,022.60 - - - -
291 Onesept 500 ml botol 30,360.00 - - - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - -
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - -
300 Stera Infuset anak pcs 3,850.00 - - - -
302 Surgical Mask Tie On box 18,150.00 6 6 6 - 10 - -
303 Swab 2 ply dus 14,040.84 - - 10 - -
304 Syringe 10 cc dus 167,266.70 - - - -
Page 251
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
305 Syringe 1cc pcs 1,045.80 - - - -
306 Syringe 1cc dus 106,523.56 - - - -
307 Syringe 3cc dus 107,421.38 - - - -
308 Syringe 5cc dus 119,090.61 - - - -

313 pcs 7,072.50 - - - -
Airvent, Luer Lock
318 Urine bag steril (t-valve) pcs 3,300.00 - - - -
PEMERIKSAAN HIV - -
319 HIV Device Box 707,143.00 14 14 14 - -
VAKSIN - -
323 DPT-HB-Hib Vial 78,991.00 - - - -
324 DT Vial 17,996.00 - - - -
325 Hepatits B Buah 23,991.00 - - - -
326 IPV Vial 139,760.00 - - - -
327 IPV Vial 144,540.00 - - - -
328 MR Vial 141,648.00 - - - -
Page 252
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
330 Td Vial 16,995.00 - - - -
ANTI RABIES - -
OBAT FILARIASIS - -
OBAT GIZI - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - - -
OBAT MALARIA - -
336 Blood Slide Kotak 18,509.00 5 5 5 - - -
337 DHP Frimal tablet 3,498.00 - - - - -
338 Kelambu GF Buah 61,077.00 - - - - -
339 Primaquin 15 mg tablet 235.00 - - - - -
OBAT KIA IBU - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 10 10 - 10 - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - -
342 Euthyrox 50 mcg tablet 735.00 - - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 50 50 50 - - -
344 Methylergometrin Injeksi ampul 3,102.00 - - - - -
345 MgSO4 20 % fls 3,328.00 6 6 6 - -
346 MgSO4 40 % fls 3,796.00 6 6 6 - -
OBAT KIA ANAK - -
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 25 50 - - -
OBAT TB PARU - -
350 Box Slide Kotak 41,342.00 - - - - -
351 Kaca Slide Kotak 30,000.00 - - - - - -
352 Kaca Slide Kotak 20,747.00 - - - - - -
Page 253
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
354 OAT Kategori I Paket 377,900.00 - - - - - -
356 Pot Sputum Pot 2,500.00 1,000 1,000 1,000 - - - -
357 Reagen Ziehl Neelsen Kit 276,000.00 15 15 15 - - - -
358 Sputum Pot Buah 2,950.00 - - - - - -
359 Tuberkulin Vial 625,900.00 - - - - - -
KUSTA - -
360 MDT PB Dewasa Blister 12,569.00 - - - - -
361 Paket ADRK II Paket 422,980.00 - - - - -
IMUNISASI - -
362 ADS 0,05 ml Buah 1,518.00 - - - - - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - - -
364 ADS 0,5 ml Buah 1,127.00 - - - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - -
369 ADS 5 ml buah 1,705.00 - - - - - -
370 ADS 5 ml Buah 1,705.00 - - - - - -
371 ADS 5 ml Buah 1,439.00 - - - - - -
372 ADS 5 ml Buah 1,500.00 - - - - - -
373 RCW Unit 2,266,454.00 - - - - - -
374 Safety Box pcs 16,608.00 - - - - - -
OBAT FLU BURUNG - -
378 Oseltamivir kapsul 12,969.00 - - - - -
Page 254
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT DIARE - -
379 Garam Oralit Sachet 257.00 - - - - - -
381 Zink Tablet tablet 551.00 200 1,000 1,200 800 400 1,000 1,000 1,000 551,000.00
OBAT HIV/AIDS - -
382 Rapid 1 : SD HIV test 11,975.00 300 300 300 - - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 25 25 25 - - -
384 Rapid Sifilis Ab test 20,400.00 - - - - -
385 RPR Sifilis test 4,250.00 - - - - -
OBAT HEPATITIS - -
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - -
Reagensia/ Alat - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - 150 150 150 1,796,250.00
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - -
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - -
391 Rapid 3 Diagnostar test 13,771.00 - - - - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - -
393 Rapid Sifilis Trepocheck test 9,697.00 75 75 75 - - -
394 RPR Sifilis test 4,250.00 - - - - -
OBAT KATARAK - -
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - - - -
OBAT PROGRAM - -
397 L- Zinc botol 31,350.00 - - - - -
398 Lagesil Suspensi botol 40,755.00 2 20 22 14 8 20 - -
REAGENTIA - -
Page 255
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
REAGENSIA - -
401 Larutan Alkohol 96% botol 242,000.00 - - - - -
402 Larutan Metanol botol 665,500.00 - - - - -
403 Reagen Benedict botol 484,000.00 - - - - -
404 Reagen Natrium Sitrat botol 514,250.00 - - - - -
405 Reagen Receker botol 2,238,500.00 - - - - -
406 Reagensia Asam Asetat botol 544,500.00 - - - - -
407 Slide test widal Unit 302,500.00 - - - - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 2 2 2 3 3 3 7,896,000.00
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - -
Masker box 450,000.00 10 10 10 4,500,000.00
Alkohol 70% 1L botol 230,000.00 5 5 5 1,150,000.00
Hand Sanitizer botol 215,000.00 5 5 5 1,075,000.00
DHP Frimal TAblet 2,134.00 9 9 9 19,206.00
TOTAL 54,611,437

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Hj.Lisna Febrianti, SKM Jahira Lubis
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 NIP. 19760210 200604 2 012 NIP. 19751213 200701 2 005
Page 256

DINKES
PUSKESMAS : LONDUT LAPORAN TRIWULAN : I (II) III IV GFK 8/IFK/3/2020 25-Aug-20
KABUPATEN : LABUHANBATU
PROVINSI UTARA
: SUMATERA UTARA
JUMLAH PEMBERIAN
HARGA SATUAN STOK PENERIMA PERSEDIA PEMAKAI STOK PERMINTA
NO NAMA OBAT SATUAN SISA STOK TOTAL
(Rp) AWAL AN AN AN OPT AN DAK APBDI APBD II TOTAL HARGA KET
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
1 Acetyl cysteine/ N-Asetil sistein tablet/kaplet/kapsul 200 mg capsule 357.00 200 - 200 - 200 - -
0
2 Acyclovir 200 mg Tablet 1,050.00 - - - - 1,100 - - - 0
3 Alopurinol tablet 100 mg tablet 97.00 - 2,500 - - 1,700 2,000 1,000 1,000 97,000 2500
0
5 Ambroxol 15 mg/5 ml botol 6,600.00 - 50 50 100 100 100 100 660,000 50
6 Ambroxol tab 30 mg tablet 330.00 - 1,000 1,000 200 2,000 2,000 2,000 660,000
1000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 - - - - - - 0
8 Aminofilin tablet 200 mg tablet 92.00 20 - 20 - 20 - - 0

0
10 Amlodipine Besilat tablet 5 mg tablet 73.00 - - - 300 2,000 - -

0
11 tablet 78.00 - 600 600 - 600 2,000 900 900 70,200
600
12 Kaplet 94.00 - - - - - -
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - - - 0
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - 600 600 - 600 - - 600
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 - 50 50 20 80 100 50 50 330,000

50
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 - 60 60 18 82 100 60 60 220,200 60
17 kaptab 261.00 - 600 600 600 2,000 2,000 2,000 522,000
kemasan strip/blister (G) 600
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - - - 0
19 Antasida Tablet box 5,594.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
20 Antasida Tablet tablet 200.00 - - - - 400 3,000 - - 0
21 Antasida Tab Tablet 355.00 - 3,000 3,000 - 3,000 3,000 3,000 3,000 1,065,000 3000
Antasida tab kunyah, kombinasi: Aluminium Hidroksida 200
22 tablet 60.00 - - - - - -
mg + Magnesium Hidroksida 200 mg 0
Antasida suspensi, kombinasi: Aluminium Hidroksida 200 mg
23 botol 2,189.00 - 100 100 150 50 200 100 100 218,900
+ Magnesium Hidroksida 200 mg 100

tube 10.000 IU/g3,071.00 - 25 25 58 25 25 25 76,775
25
25 pot 4,540.00 - - - 25 24 24 24 108,960
Asam Salisilat 3% 0
supposito
26 Antihemoroid, Kombinasi sup: bismut subgalat heksaklorofen 3,325.00 - - - - - -
ria 0
27 Arkine 100 tablet 687.50 - - - - - - 0
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - - - - 0
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - - - - - - 0
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 - 1,000 - - - 100 100 100 24,500 1000
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - - - 0
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - - - - - - - 0
33 Bedak salisil serbuk 2% dus 1,040.00 - 20 - - - 50 - - 20
34 Bedak Salisil Kotak 8,000.00 - - - - 34 34 34 272,000 0
35 Betametason krim 0,5 mg/g tube 3,388.00 - - - - 30 - - - 0
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - - - 25 - - 0
37 Biosat 1,5 Serum antitetanus (A.T.S) inj 1500 IU/amp (i.m) Ampul 130,999.00 - - - - - - - 0
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - - - - 0
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - - - - - - - -
selaput 0
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 - - - - - - 0
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - - - - - - 0
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - - - - 0
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - - - 0
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - - - - 0
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - - - 0
tablet
46 Cetirizin Hydrochloride salut 94.00 - - - - 400 2,000 - -
selaput 0
47 Cetirizine tablet 10 mg tablet 101.00 - 1,500 1,500 1,500 1,000 1,000 1,000 101,000 1500
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 - - - - - - 0
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - - - - - 0
tablet
50 salut 165.00 - - - - - -
selaput 0
51 kapsul 770.00 - 300 300 - 350 500 300 300 231,000
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
52 Codeine 10 mg tablet 600.00 - - - - - - 0
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 38 - 38 6 32 - - - 0
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 - - - - - - -
trimetoprim 40 mg (susp 240 mg) 0
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 mg tablet 133.00 - - - 200 500 500 500 66,500
(tab/kaptab 480 mg) 0
56 tablet 47.00 - - - - 1,100 2,000 - -
tab/kaps/kapl/ 50 mg 0
Deksametason sodium
57 ampul 1,152.00 - 30 30 30 - -
phosphate/Dexamethasone/Deksametason injeksi 5 mg/ml 30
58 Dexamethason inj Ampul 4,500.00 - - - 30 - - - 0
59 Dexametason Tablet 0,5 mg Tablet 33.00 - 500 500 - 200 500 500 500 16,500 500
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - - - 0
61 Dekstrofen Syrup Botol 11,550.00 - 50 50 - 50 50 - - 50
62 Diazepam 2 mg Tablet 86.00 - - - - - - 0
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - - - 0
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 - 5 5 5 - - 5
65 Diclofenac Sodium 25 mg Tablet 141.00 - 1,000 1,000 1,000 1,000 1,000 1,000 141,000 1000
66 Diclofenac Sodium 50 mg Tablet 136.00 - - - - 2,800 2,800 2,800 380,800 0
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - - - 10 90 100 - - 0
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - 120 120 120 90 90 120
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - - - 0
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - - - - 0
71 Digoksin 0,25 mg Tablet 104.00 - - - - - - 0
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - - - - - - 0
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 50 50 100 10 40 50 50 50 139,050
Plastik 50
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 - - - - 2,200 - - - 0
75 Domperidon tablet 10 mg tablet 86.00 - - - - - - 0
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - - - - - - 0
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 - - - - - - 0
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - - - 0
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - - - - - 5 - - 0
kaptab
80 Eritromisin kapl 500 mg salut 765.00 - - - - - -
selaput 0
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - - - - - 0
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 - - - - - - - - 0
83 Eugenol cairan botol 21,091.00 - 1 1 1 - - - - 1
84 Fenobarbital tablet 30 mg tablet 165.00 - - - - - - - 0
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - - - 0
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Fitomenadion/Phytomenadion (Vit K) tablet/kaplet salut gula
87 tablet 747.00 - - - - - 500 - -
10 mg 0
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 - 400 400 400 300 300 300 239,100 400
89 Fitomenadion / Phytomenadion (Vitamin k1) injeksi 2 mg/ml ampul 3,867.00 - 30 30 - 30 30 30 30 116,010 30
90 Fituno Tab tablet 4,163.10 - - - - - - 0
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - - - - - - 0
92 Furosemide tablet 40 mg tablet 77.00 - 200 200 - 170 300 - - 200
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - - - 0
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - 5 5 5 - - - 5
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - 5 5 5 - - 5
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 - 2,000 2,000 700 1,300 1,000 1,000 1,000 125,000 2000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 23 20 43 - 43 - - - 20
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 - - - - 600 500 500 500 122,500 0
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - - - - 0
100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - - - 0
101 Haloperidol 0,5 mg Tablet 55.00 - - - - - - - 0
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - - - - 0
103 Hidrokortison krim 2,5 % tube 2,640.00 - - - - 48 - - - 0
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - - - 0
105 Hustab Syrup botol 11,550.00 - 50 50 38 62 150 100 100 1,155,000 50
106 Hustab P Tablet 8 mg Tablet 256.67 - 900 900 800 900 900 900 231,003 900
107 Hustab Tablet tablet 437.00 - - - - - - - - 0
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - - - - 800 -
selaput 0
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 - - - - - -
selaput 0
110 Ibuprofen 200 mg Tablet 550.00 - - - - - - 0
111 Ibuprofen 400 mg Tablet 800.00 - 500 500 - 300 1,000 300 300 240,000 500
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 - - - - - - - - 0
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - - - - 0
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - - - - - - 0
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - 880 120 1,000 - - 0
Kalsium Laktat/ Calcium lactate (Kalk) tablet/kapsul/kaplet
116 tablet 63.00 - 2,000 2,000 - 1,600 2,000 1,500 1,500 94,500
500 mg 2000
117 Kanamycin 1 gr inj vial 10,768.00 - - - - - - 0
118 Kaptopril 12,5 mg tablet 68.00 - 1,000 1,000 600 400 2,000 1,500 1,500 102,000 1000
119 Ketokenazol tablet 200 mg tablet 278.00 - - - - - - - - 0
120 Ketokonazol tablet 200 mg tablet 297.00 - - - - - - 0
121 Kloramfenicol kapsul 250 mg Capsule 320.00 - - - - - - 0
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - - - - - 0
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - - - 0
124 Kloramfenikol salep mata 1 % Tube 2,007.00 - - - - 24 - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - - - - - - -
Plastik 0
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - - - - - 0
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 - - - 500 500 1,500 - - 0
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - - - 0
129 Klorfeniramin maleat tablet 25.00 - 1,600 1,600 1,600 1,500 1,500 1,500 37,500 1600
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 200 200 - - 500 500 500 151,500 200
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 - - - - 2,000 - - 0
132 Lidocaine Injeksi 2 % ampul 1,203.00 - - - - - - 0
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 - 500 500 500 500 1,000 500 500 130,000 500
134 Meloksikam 7,5 mg tablet 795.68 - - - 600 200 1,500 - - 0
135 Meloxicam tab15 mg tablet 1,438.80 - 1,500 1,500 - 900 1,000 700 700 1,007,160 1500
136 Meloxicam 15 mg Tablet 980.00 - - - - - - 0
tablet
137 salut 106.00 - 1,000 1,000 - 700 - 2,000 - -
tablet/kapsul/kaplet/kaptab 500 mg, kemasan strip/blister (G)
selaput 1000
138 Metilprednisolon/methylprednisolone tab/kaps/kapl 4 mg tablet 137.00 - 2,000 2,000 2,000 - - 2000
139 Metilprednisolon tablet 4 mg tablet 146.00 - - - 1,200 1,000 1,000 1,000 146,000 0
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - - - 0
141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - - - 0
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 - - - - - - -
selaput 0
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - - - 0
144 tablet 80.00 - 200 200 200 - - -
(hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 mg 200
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - - - - - - 0
146 Metronidazole tablet 500 mg tablet 264.00 - 600 600 1,000 - 400 1,000 700 700 184,800 600
147 MgSO4 20 % botol 13,500.00 - - - - - - - 0
148 MgSO4 40 % botol 13,500.00 - - - - 6 - - 0
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 37 24 61 - 37 - - - 24
150 NaCl 0,9 % 500 ml botol 6,840.00 36 20 - - - 36 - - - 20
151 Natrium Diklofenak tablet/kapsul/kaplet salit enterik 25 mg tablet 132.00 - - - - 1,000 - 1,000 - - 0
152 Natrium Diklofenak tablet/kapsul/kaplet salit enterik 50 mg tablet 127.00 - - - - 800 1,000 - - 0
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 - 500 - - 1,000 1,500 500 500 55,000 500
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 - - - - - - 0
155 Nystatin tablet 500.000 IU Tablet 886.00 - - - - - - 0
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - - - - 0
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - - - 0
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - - - - 0
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - - - - 0
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - - - - 0
161 Omeprazol Tab Tablet 650.00 - 400 400 - 240 1,000 200 200 130,000 400
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
163 Paracetamol Tab 500 mg tablet 290.00 - - - - - - 0
164 Paracetamol kaplet 500 mg kaplet 165.00 - 3,000 3,000 1,400 600 2,000 3,000 3,000 495,000 3000
Paracetamol/parasetamol drops 100 mg/ml btl @15 ml (60
165 bottle 6,981.00 - - - - 4 5 - -
ml/0,6 ml) (G) 0
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - 30 30 50 - 100 - - 30
167 Pehacain Injeksi ampul 3,113.06 - - - 90 60 100 - - 0
168 Pehacain Injeksi Ampul 3,113.05 - 200 200 200 100 100 100 311,305 200
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - 1,700 300 3,000 - - 0
170 Pehastan 500 mg tablet 445.50 1,000 2,600 3,600 400 600 - 3,000 3,000 3,000 1,336,500 2600
171 Pehavral tablet 935.00 - - - - - 1,000 - - 0
172 Perak sulfadiazin krim 1% tube 20,700.00 - - - - - - - 0
173 Peridol Syrup 60 ml botol 19,800.00 - 24 24 24 - - - 24
174 Perio Kin Spray Chlorhexidin Gluconat/ Klorheksidin 0,2 % botol 124,355.00 - - - - 2 2 2 248,710 0
175 Phaproxin 500 mg tablet 880.00 - 100 100 100 100 100 100 88,000 100
176 Pirantel pamoat / pyrantel pamoate tab/kaps/kapl 125 mg tablet 302.00 - - - - 100 - - - 0
177 Pirantel pamoat 125 mg tab tablet 322.00 - 100 100 100 - - 100
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - - - - - - 0
179 Pirantel Pamoat syrup botol 10,778.00 - - - - - - 0
180 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 124.00 - - - 700 1,800 2,500 - - 0
181 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) tablet 129.00 - 3,200 3,200 3,200 1,000 1,000 1,000 129,000 3200
182 Prednison tablet 5 mg tablet 76.00 - 500 500 100 400 500 500 500 38,000 500
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 - - - - - - - - - 0
184 Pularex Attapulgit tab 630 mg tablet 142.00 600 - 600 - 600 - - - 0
185 Pyridol Syrup 60 ml botol 18,150.00 60 - 60 15 45 100 - - 0
186 Ranitidin 150 mg Tablet tablet 660.00 - 1,200 1,200 2,000 - 3,000 2,000 2,000 1,320,000 1200
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 63 100 163 63 - - - - 100
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 100 - 100 100 - - - 0
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - - - - - 0
190 Retinol/ Vit A 200.000 UI capsule 543.99 - - - - - - 0
191 Ringer Laktat 500 ml botol 7,630.00 23 20 43 - 23 20 20 20 152,600 20
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - - - 0
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - 500 500 - 500 300 300 300 18,900 500
194 Salbutamol 2 mg tab tablet 67.00 - - - - - - 0
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 - 500 500 300 200 500 500 500 40,000 500
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - - - - - - 0
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 18 - 18 2 16 - - - 0
198 Salep 2-4, kombinasi: asam salisilat 2% + belerang endap 4% pot 2,654.00 - - - - 53 - - -
0
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - - - - - - 0
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - - - - 0
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - - - - - - 0
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 - - - - 510 - 1,000 - -
Selaput 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
203 Simvastatin tablet 10 mg Tablet 117.00 - 600 600 - 600 1,020 1,020 1,020 119,340 600
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 - - - - - - -
selaput 0
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - 4 4 4 - - - 4
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - - - 0
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 - - - - - - - 0
208 Tiamin (Vitamin B1) Tablet/Kapsul/kaplet 50 mg (HCL/Nitrat) tablet 84.00 - - - - - 1,500 - -

0
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - 500 500 500 700 700 700 60,200 500
tablet
210 salut 93.00 - - - - - -
selaput 0
211 Vapril 25 mg tablet 193.00 - - - - - - 0
212 Ventolin Rotahaler (Alat Hirup Salbutamol 200 mcg/kapsul) box 6,550.00 - - - - - - - 0
213 Vitamin B Kompleks tablet 123.00 - 500 500 - 1,200 1,000 1,000 1,000 123,000 500
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 - 200 200 180 120 200 100 100 113,600 200
215 Vitamin B12 tablet 50 mcg tablet 52.00 - 1,000 1,000 - - 2,000 2,000 2,000 104,000 1000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - - - 0
217 Vitamin B6 10 mg tablet 138.00 - - - - - - - 0
Botol
218 Wida Bes Asetat Ringer (Asering) (Softbag, Flexy bag, plabot 9,646.00 - - - - - -
Plastik 0
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - - - - - 100 - - 0
OBAT GIZI (DAK 2019) - - 0
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 20,000 33,600 53,600 11,800 8,200 39,200 39,200 39,200 14,582,400 33600
221 Hemafort tablet 834.90 2,200 2,000 4,200 400 1,800 3,600 3,600 3,600 3,005,640 2000
222 magnesium chloride anhydrous, potassium chloride, zinc sachet 3,116.00 30 - - 2 28 - - -
acetate) 0
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - - - 0
224 Retnol Acetat/ Retinol (Vitamin A) Kaps Lunak 200.000 IU Kapsul 581.00 - - - - - - 0
BAHAN MEDIS HABIS PAKAI (DAK ) - - 0
225 Allkohol 70% bottle 28,733.33 - - - - - - 0
226 Alkohol 70% 1L botol 28,750.00 - - - - - - - - 0
227 Arm sling L buah 17,424.00 - - - - - - 0
228 Arm sling M buah 17,424.00 - - - - - - 0
229 Arm sling S buah 17,424.00 - - - - - - 0
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - - - 0
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 - - - - - - 0
232 Aximed Syringe 1 cc Dus 103,750.00 - - - - 1 1 1 103,750 0
233 Aximed Syringe 3 cc Dus 103,125.00 - 1 1 - 1 - - - 1
234 Blood Lancet box 16,022.60 - - - - - - - - 0
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - - - - - 0
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - - - - - 0
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 - 12 12 12 24 24 24 834,480 12
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - - - - - - 0
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - - - - - - 0
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 - - - - - - - 0
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - 108 108 108 - - - 108
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - - - - - 0
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - - - 3 - 3 - - - 0
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - - - 0
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - - - 0
253 Chirurgic Gloves, size 8 pcs 9,525.12 - - - - - - 0
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - - - - 0
255 Dermafix T 10x12cm pcs 6,939.90 - - - - - - 0
256 Examination Gloves size L box 58,564.00 - - - - 10 5 5 292,820 0
257 Examination Gloves size M box 58,564.00 - - - - 10 5 5 292,820 0
258 Examination Gloves size S box 58,564.00 - - - - 10 5 5 292,820 0
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - - - - 0
260 Folley catheter 2 way no. 16 pcs 8,800.00 - - - - - - 0
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - - - 0
262 Germany Tro-Sensosurge Steril Glove 7.5 pasang 7,254.00 - 50 50 50 - - 50
263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 - 50 50 50 - - 50
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - - 0
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - - 0
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - - 0
267 Hb Sahli set 96,800.00 - - - - - - 0
268 Hidrogen Peroxide 3% botol 3,864.00 - - - - - - 0
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - - - 0
270 Infuset pcs 6,166.16 - 50 50 - - - - - 50
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - - - - - 0
275 Kapas pembalut 250 gr roll 13,733.33 - - - - - - 0
276 Kapas pembalut 250 gr roll 13,750.00 - - - - - - 0
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 10 10 10 - - - 10
278 Kasa kompres steril 40 x 40 pcs 1,760.00 - 40 40 - - - - - 40
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - - - - - - - - 0
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - - - - - 0
282 Lysol 1 liter botol 47,150.00 - - - - - - 0
283 Masker Ear Loop Box 20,202.00 - - - - - - 0
284 Masker Tie on Box 19,869.00 - - - - - - 0
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - - - 0
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - - - 0
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - - - - 0
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - - - 0
289 Onemed Alcohol Swab botol 11,000.00 - - - - - - 0
290 Onemed Blood Lancet box 16,022.60 - - - - - - 0
291 Onesept 500 ml botol 30,360.00 - - - - - - 0
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 - - - - - - 0
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - - - - - 0
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - - - - - - 0
295 Safeglove Examination Gloves L box 39,182.00 - - - - - - 0
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - - - - - 0
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - - - - 0
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - - - - 0
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - - - - 0
300 Stera Infuset anak pcs 3,850.00 - - - - - - - 0
301 Surgical Mask Earloop box 18,150.00 - - - - 10 - - 0
302 Surgical Mask Tie On box 18,150.00 - 12 12 12 10 - - 12
303 Swab 2 ply dus 14,040.84 - - - - - - 0
304 Syringe 10 cc dus 167,266.70 - - - - - - 0
305 Syringe 1cc pcs 1,045.80 - - - - - - 0
306 Syringe 1cc dus 106,523.56 - - - - - - 0
307 Syringe 3cc dus 107,421.38 - - - - - - 0
308 Syringe 5cc dus 119,090.61 - - - - - - 0
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - - - 0
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - - - 0
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - - - 0
312 Tp. Disposable Syringe 5 cc pcs 892.78 - - - - - - 0
Tp. Infusion Set Pediatric 60 drops/ml with Y Type, Airvent,
313 pcs 7,072.50 - - - - - -
Luer Lock 0
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - - - 0
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - - - 0
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - - - 0
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 - - - - - - 0
318 Urine bag steril (t-valve) pcs 3,300.00 - - - - - - 0
PEMERIKSAAN HIV - - 0
319 HIV Device Box 707,143.00 - 14 14 14 - - 14

0
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
SUMBER DANA APBD I - - 0
VAKSIN - - 0
321 BCG +Pelarut BCG Vial 61,996.00 - - - - - - 0
322 Campak + Pelarut Campak Vial 28,204.00 - - - - - - 0
323 DPT-HB-Hib Vial 78,991.00 - - - - - - 0
324 DT Vial 17,996.00 - - - - - - 0
325 Hepatits B Buah 23,991.00 - - - - - - 0
326 IPV Vial 139,760.00 - - - - - - 0
327 IPV Vial 144,540.00 - - - - - - 0
328 MR Vial 141,648.00 - - - - - - 0
329 Polio+ Dropper Polio Vial 19,954.00 - - - - - - 0
330 Td Vial 16,995.00 - - - - - - 0
ANTI RABIES - - 0
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - - - 0
OBAT FILARIASIS - - 0
332 Albendazol 400 mg tablet 258.74 - - - - - 500 - - 0
OBAT GIZI - - 0
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - - - - - - 0
334 Vitamin 100.000 IU (Biru) kapsul 310.00 50 - 50 50 - - - 0
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - - - - 0
OBAT MALARIA - - 0
336 Blood Slide Kotak 18,509.00 - 6 - - - - - 6
337 DHP Frimal tablet 3,498.00 - - - - - 0
338 Kelambu GF Buah 61,077.00 - - - - - 0
339 Primaquin 15 mg tablet 235.00 - - - - - 0
OBAT KIA IBU - - 0
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - 10 10 10 - - 10
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - - - 0
342 Euthyrox 50 mcg tablet 735.00 - - - - - - 0
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - 20 20 - 20 - - 20
344 Methylergometrin Injeksi ampul 3,102.00 - 50 50 - 50 - - - 50
345 MgSO4 20 % fls 3,328.00 - - - - - - 0
346 MgSO4 40 % fls 3,796.00 - - - - - - 0
OBAT KIA ANAK - - 0
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - - 0
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - - - 0
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - 25 25 25 - 20 25 25 65,000 25
OBAT TB PARU - - 0
350 Box Slide Kotak 41,342.00 - - - - - - 0
351 Kaca Slide Kotak 30,000.00 - - - - - - 0
352 Kaca Slide Kotak 20,747.00 - - - - - - 0
353 OAT Kategori Anak Paket 232,518.00 - - - - - - 0
354 OAT Kategori I Paket 377,900.00 - - - - - - - 0
355 OAT Kategori II Paket 1,259,990.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
356 Pot Sputum Pot 2,500.00 - 1,000 1,000 1,000 - - 1000
357 Reagen Ziehl Neelsen Kit 276,000.00 - 13 13 13 - - 13
358 Sputum Pot Buah 2,950.00 - - - - - - - 0
359 Tuberkulin Vial 625,900.00 - - - - - - 0
KUSTA - - 0
360 MDT PB Dewasa Blister 12,569.00 - - - - - - 0
ALAT DETEKSI RESIKO KEHAMILAN - - 0
361 Paket ADRK II Paket 422,980.00 - - - - - - 0
IMUNISASI - - 0
362 ADS 0,05 ml Buah 1,518.00 - - - - - - 0
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - - - 0
364 ADS 0,5 ml Buah 1,127.00 - - - - - - 0
365 ADS 0,5 ml Buah 1,090.00 - - - - - - 0
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - - - 0
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - - 0
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - - - 0
369 ADS 5 ml buah 1,705.00 - - - - - - 0
370 ADS 5 ml Buah 1,705.00 - - - - - - 0
371 ADS 5 ml Buah 1,439.00 - - - - - - 0
372 ADS 5 ml Buah 1,500.00 - - - - - - 0
373 RCW Unit 2,266,454.00 - - - - - - 0
374 Safety Box pcs 16,608.00 - - - - - - 0
375 Safety Box 2,5 ml Buah 12,500.00 - - - - - - 0
376 Safety Box 5 ml Buah 20,394.00 - - - - - - 0
377 Vaccine Carrier buah 1,870,000.00 - - - - - - 0
OBAT FLU BURUNG - - 0
378 Oseltamivir kapsul 12,969.00 - - - - - - 0
OBAT DIARE - - 0
379 Garam Oralit Sachet 257.00 140 200 340 - 340 - - - 200
380 Garam Oralit Sachet 253.00 - - - - - - - 0
381 Zink Tablet tablet 551.00 - 500 500 - 500 - - - 500
OBAT HIV/AIDS - - 0
382 Rapid 1 : SD HIV test 11,975.00 200 - 200 200 - - 0
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - - - 0
384 Rapid Sifilis Ab test 20,400.00 - - - - - - 0
385 RPR Sifilis test 4,250.00 - - - - - - 0
OBAT HEPATITIS - - 0
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - - - 0
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - - - 0
Reagensia/ Alat - - 0
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - - 500 500 500 5,987,500 0
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - - - 0
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - - - 0
391 Rapid 3 Diagnostar test 13,771.00 - - - - - - 0
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - - - 0
393 Rapid Sifilis Trepocheck test 9,697.00 - 75 75 75 - - 75
394 RPR Sifilis test 4,250.00 - - - - - - 0
SUMBER DANA APBD II - - 0
OBAT KATARAK - - 0
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - - - - 0
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - - - - 0
OBAT PROGRAM - - 0
397 L- Zinc botol 31,350.00 - - - - - - 0
398 Lagesil Suspensi botol 40,755.00 - 8 8 - 8 100 - - 8
REAGENTIA - - 0
399 Objek Gelas Kotak 50,000.00 - - - - - - 0
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - - - 0
REAGENSIA - - 0
401 Larutan Alkohol 96% botol 242,000.00 - - - - - - 0
402 Larutan Metanol botol 665,500.00 - - - - - - 0
403 Reagen Benedict botol 484,000.00 - - - - - - 0
404 Reagen Natrium Sitrat botol 514,250.00 - - - - - - 0
405 Reagen Receker botol 2,238,500.00 - - - - - - 0
406 Reagensia Asam Asetat botol 544,500.00 - - - - - - 0
407 Slide test widal Unit 302,500.00 - - - - - - 0
BELANJA STICK NARKOBA - - 0
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - - - 0
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - 2 2 2 5,264,000 0
PENINGKATAN KESEHATAN MASYARAKAT - - 0
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - - - - 0
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - - - 0
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1,000 1,000 1,000 110,000
Masker box 450,000.00 10 10 10 4,500,000
Alkohol 70% 1L botol 230,000.00 5 5 5 1,150,000
Hand Sanitizer botol 215,000.00 15 20 20 4,300,000
TOTAL 60,112,273

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Sofia Perpetua Siregar,SKM,MKM Marito
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 NIP . 19690303 199203 2 002 NIP . 19870321 200903 2004
90
DINKES
PUSKESMAS : AEK KANOPAN LAPORAN TRIWULAN : I (II) III IV GFK 7/IFK/3/2020 24-Aug-20
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 - - - - - 2,000 - - 0
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - - - - - - - 0
3 Alopurinol tablet 100 mg tablet 97.00 700 1,500 2,200 1,800 400 2,000 2000 2,000 194,000 1500
4 Alopurinol tablet 100 mg tablet 104.00 - - - - - - - 0
5 Ambroxol 15 mg/5 ml botol 6,600.00 70 150 220 180 40 200 200 200 1,320,000 150
6 Ambroxol tab 30 mg tablet 330.00 900 1,000 1,900 1,500 400 2,000 2000 2,000 660,000 1000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 30 - 30 - 30 - - - 0
8 Aminofilin tablet 200 mg tablet 92.00 500 - 500 - 500 - - - 0
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 500 - 500 - 500 - - - 0
10 Amlodipine Besilat tablet 5 mg tablet 73.00 100 - 100 100 - - - - 0
11 tablet 78.00 300 1,500 1,800 1,500 300 1,500 1500 1,500 117,000 1500
12 Kaplet 94.00 2,400 600 3,000 600 2,400 2,100 2100 2,100 197,400 600
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - - - - - 0
14 Amoksisilin 250 mg kapsul Kapsul 203.00 900 1,000 1,900 1,000 900 3,000 1000 1,000 203,000 1000
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 82 100 182 139 43 150 100 100 660,000 100
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 102 120 222 158 64 150 120 120 440,400 120
17 kaptab 261.00 3,700 6,000 9,700 9,700 - 5,000 2000 2,000 522,000 6000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - - - - - 0
19 Antasida Tablet box 5,594.00 - - - - - - - - 0
20 Antasida Tablet tablet 200.00 7,300 - 7,300 5,600 1,700 5,000 - - 0
21 Antasida Tab Tablet 355.00 - 2,000 2,000 2,000 - 2,000 2000 2,000 710,000 2000
Page 270
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
22 tablet 60.00 - - - - - - - - 0
23 botol 2,189.00 50 150 200 181 19 150 150 150 328,350 150

+ Polimiksin 10.000
3,071.00
IU/g 66 25 91 41 50 60 25 25 76,775 25

25 pot 4,540.00 78 48 126 102 24 48 48 48 217,920 48
Asam Salisilat 3%

26 3,325.00 30 - 30 - 30 30 30 30 99,750 0
heksaklorofen ria
27 Arkine 100 tablet 687.50 100 - 100 - 100 - - - 0
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - 5,000 - - 0
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 32 - 32 10 22 40 - - 0
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 250 1,000 1,250 1,200 50 1,000 1000 1,000 245,000 1000
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - - - - - 0
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 5 - 5 - 5 - - - 0
33 Bedak salisil serbuk 2% dus 1,040.00 58 - 58 - 58 50 - - 0
34 Bedak Salisil Kotak 8,000.00 50 50 50 - 20 20 20 160,000 50
35 Betametason krim 0,5 mg/g tube 3,388.00 43 - 43 12 31 60 - - 0
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 25 25 25 - 50 50 50 67,000 25
37 Ampul 130,999.00 1 - 1 - 1 15 - - 0
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 1 - 1 - 1 - - - 0
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 60 60 120 90 30 900 - - 60
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 88 - 88 88 - 72 - - 0
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 24 72 96 96 - 144 144 144 451,872 72
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - - - - - - 0
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - - - - - 0
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - - - - - - 0
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - - - - - 0
tablet
46 Cetirizin Hydrochloride salut 94.00 - - - - - - - - 0
selaput
47 Cetirizine tablet 10 mg tablet 101.00 1,100 500 1,600 1,600 - 5,000 500 500 50,500 500
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 2 150 152 152 - 200 200 200 594,600 150
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - - 1,000 - - 0
Page 271
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
50 salut 165.00 300 - 300 200 100 500 500 500 82,500 0
selaput
51 kapsul 770.00 - - - - - - - - 0
52 Codeine 10 mg tablet 600.00 500 - 500 - 500 - - - 0
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - - - - - - 0
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 100 50 150 75 75 150 100 100 219,000 50
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 500 1,000 1,500 1,200 300 3,000 700 700 93,100 1000
56 tablet 47.00 - - - - - 4,000 - - 0
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 - - - - - 100 100 100 115,200 0
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - - - 100 - - 0

59 Dexametason Tablet 0,5 mg Tablet 33.00 900 1,500 2,400 2,100 300 4,000 1500 1,500 49,500 1500
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - - - - - 0
61 Dekstrofen Syrup Botol 11,550.00 89 - 89 21 68 200 - - 0
62 Diazepam 2 mg Tablet 86.00 100 - 100 - 100 - - - 0
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 100 - 100 30 70 - - - 0
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 - - - - - - - - 0
65 Diclofenac Sodium 25 mg Tablet 141.00 600 1,000 1,600 1,200 400 3,000 1000 1,000 141,000 1000
66 Diclofenac Sodium 50 mg Tablet 136.00 - 2,800 2,800 2,800 - 3,000 2800 2,800 380,800 2800
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - - - - - 200 - - 0
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - 90 90 90 - 200 200 90
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - - - - - 0
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - - - - - 0
71 Digoksin 0,25 mg Tablet 104.00 600 300 900 300 600 1,000 600 600 62,400 300
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 500 - 500 - 500 - - - 0
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 127 50 177 90 87 100 100 100 278,100 50
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 400 - 400 400 - - - - 0
75 Domperidon tablet 10 mg tablet 86.00 1,000 - 1,000 200 800 1,000 1000 1,000 86,000 0
Page 272
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 12 - 12 - 12 12 12 12 70,800 0
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 12 - 12 - 12 12 12 12 72,000 0
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - - - - - 0
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 42 - 42 - 42 - - - 0
kaptab
80 Eritromisin kapl 500 mg salut 765.00 800 500 1,300 700 600 3,000 600 600 459,000 500
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - - - - - 0
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 36 - 36 20 16 120 - - 0
83 Eugenol cairan botol 21,091.00 - 2 2 2 - - - - 2
84 Fenobarbital tablet 30 mg tablet 165.00 200 - 200 200 - - - - 0
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - - - - - 0
86 Fenol Gliserol Tetes Telinga botol 2,764.00 24 - 24 - 24 24 - - 0
87 tablet 747.00 200 - 200 - 200 - - - 0
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 500 500 1,000 500 500 2,000 500 500 398,500 500
89 ampul 3,867.00 82 30 112 30 82 30 30 30 116,010 30
mg/ml
90 Fituno Tab tablet 4,163.10 - - - - - 3,000 300 300 1,248,930 0
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - - - - - - 0
92 Furosemide tablet 40 mg tablet 77.00 400 - 400 - 400 500 - - 0
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - - - - - 0
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - - - - - 100 24 24 67,440 0
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - - - - - 100 24 24 106,848 0
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1,900 2,000 3,900 3,900 - 3,000 1000 1,000 125,000 2000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 - - - - - - - - 0
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 400 1,000 1,400 1,000 400 2,000 1500 1,500 367,500 1000
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - - - - - 0

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - - - - - 0
101 Haloperidol 0,5 mg Tablet 55.00 500 - 500 - 500 - - - 0
102 Hidroklorotiazid tab 25 mg tablet 163.00 1,300 - 1,300 - 1,300 - - - 0
103 Hidrokortison krim 2,5 % tube 2,640.00 41 48 89 71 18 48 24 24 63,360 48
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - - - - - 0
Page 273
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
105 Hustab Syrup botol 11,550.00 64 150 214 182 32 200 100 100 1,155,000 150
106 Hustab P Tablet 8 mg Tablet 256.67 760 2,400 3,160 2,700 460 3,000 3000 3,000 770,010 2400
107 Hustab Tablet tablet 437.00 1,500 3,600 5,100 4,490 610 3,000 3600 3,600 1,573,200 3600
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 800 - 800 500 300 3,000 0
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 - - - - - - 0
selaput
110 Ibuprofen 200 mg Tablet 550.00 - 500 500 500 - 500 500 500 275,000 500
111 Ibuprofen 400 mg Tablet 800.00 300 300 600 300 300 3,000 500 500 400,000 300
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 50 - 50 - 50 100 - - 0
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - - - - - - 0
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 600 - 600 - 600 1,000 1000 1,000 89,000 0
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 1,050 - 1,050 540 510 3,000 - - 0
116 tablet 63.00 2,000 1,000 3,000 2,200 800 3,000 2500 2,500 157,500 1000
117 Kanamycin 1 gr inj vial 10,768.00 - - - - - - - - 0
118 Kaptopril 12,5 mg tablet 68.00 400 500 900 600 300 2,000 2000 2,000 136,000 500
119 Ketokenazol tablet 200 mg tablet 278.00 - - - - - - - - 0
120 Ketokonazol tablet 200 mg tablet 297.00 150 - 150 50 100 2,000 - - 0
121 Kloramfenicol kapsul 250 mg Capsule 320.00 600 - 600 400 200 1,000 - - 0
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 500 700 1,200 700 500 500 500 500 330,000 700
123 Kloramfenikol Salep 2% tube 3,349.00 24 - 24 - 24 24 - - 0
124 Kloramfenikol salep mata 1 % Tube 2,007.00 24 24 48 24 24 24 24 24 48,168 24
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 50 - 50 - 50 - - - 0
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - - - - - - - 0
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 1,100 - 1,100 1,000 100 5,000 - - 0
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - - - - - 0
129 Klorfeniramin maleat tablet 25.00 - 5,000 5,000 5,000 - 5,000 5000 5,000 125,000 5000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 1,000 1,000 1,000 - 400 400 400 121,200 1000
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 1,180 - 1,180 1,140 40 4,000 - - 0
132 Lidocaine Injeksi 2 % ampul 1,203.00 - - - - - - - - 0
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 300 500 800 500 300 3,000 300 300 78,000 500
134 Meloksikam 7,5 mg tablet 795.68 - - - - - 3,000 - - 0
Page 274
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
135 Meloxicam tab15 mg tablet 1,438.80 600 500 1,100 1,000 100 3,000 3000 3,000 4,316,400 500
136 Meloxicam 15 mg Tablet 980.00 - - - - - - - - 0
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 - - - - - 5,000 - - 0
138 tablet 137.00 1,000 - 1,000 700 300 2,000 - - 0
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - 1,000 1,000 1,000 - 1,000 1000 1,000 146,000 1000
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - - - - - 0

141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - - 2,000 - - 0
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 1,900 1,000 2,900 1,900 1,000 2,000 2000 2,000 444,000 1000
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - - - - - 0
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 2,000 700 2,700 2,100 600 3,000 2000 2,000 160,000 700
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 20 20 40 35 5 100 30 30 118,500 20
146 Metronidazole tablet 500 mg tablet 264.00 500 1,500 2,000 1,900 100 2,000 500 500 132,000 1500
147 MgSO4 20 % botol 13,500.00 - - - - - - - - 0
148 MgSO4 40 % botol 13,500.00 4 - 4 - 4 - - - 0
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 38 48 86 53 33 72 48 48 172,080 48
150 NaCl 0,9 % 500 ml botol 6,840.00 161 60 221 141 80 60 60 60 410,400 60
151 tablet 132.00 150 - 150 150 - 2,000 - - 0
25 mg
152 tablet 127.00 1,300 - 1,300 900 400 2,000 - - 0
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 800 - 800 300 500 1,000 700 700 77,000 0
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 1,100 - 1,100 200 900 1,000 - - 0
155 Nystatin tablet 500.000 IU Tablet 886.00 - 300 300 300 - 200 200 200 177,200 300
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - - - - - - 0
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - - - - - 0
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - - - - - - 0
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - - - - - - 0
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - - - - - - 0
161 Omeprazol Tab Tablet 650.00 - - - - - 3,000 400 400 260,000 0
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 29 - 29 26 3 100 - - 0
163 Paracetamol Tab 500 mg tablet 290.00 - - - - - - - - 0
Page 275
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
164 Paracetamol kaplet 500 mg kaplet 165.00 2,300 6,200 8,500 8,500 - 5,200 5200 5,200 858,000 6200
165 bottle 6,981.00 12 - 12 12 - 200 - - 0
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 25 - 25 25 - 200 - - 0
167 Pehacain Injeksi ampul 3,113.06 - - - - - - - - 0
168 Pehacain Injeksi Ampul 3,113.05 63 320 383 379 4 200 200 200 622,610 320
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - - - 4,000 - - 0
170 Pehastan 500 mg tablet 445.50 2,000 3,000 5,000 4,700 300 5,000 2000 2,000 891,000 3000
171 Pehavral tablet 935.00 600 - 600 300 300 4,000 - - 0
172 Perak sulfadiazin krim 1% tube 20,700.00 24 - 24 19 5 5 - - 0
173 Peridol Syrup 60 ml botol 19,800.00 - - - - - - - - 0
174 botol 124,355.00 8 3 11 3 8 20 - - 3
0,2 %
175 Phaproxin 500 mg tablet 880.00 800 200 1,000 350 650 3,000 1800 1,800 1,584,000 200
176 tablet 302.00 - - - - - 2,000 - - 0
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 - 500 500 500 - 500 500 500 161,000 500
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 2 - 2 2 - - - - 0
179 Pirantel Pamoat syrup botol 10,778.00 5 - 5 - 5 50 - - 0
180 Tablet 124.00 650 - 650 400 250 - - - 0
(HCl)
181 tablet 129.00 1,000 1,000 2,000 1,800 200 3,000 3000 3,000 387,000 1000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 - 1,500 1,500 1,500 - 2,000 2000 2,000 152,000 1500
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 1,600 - 1,600 700 900 2,000 - - 0
184 Pularex Attapulgit tab 630 mg tablet 142.00 500 500 1,000 700 300 3,000 200 200 28,400 500
185 Pyridol Syrup 60 ml botol 18,150.00 135 - 135 52 83 150 - - 0
186 Ranitidin 150 mg Tablet tablet 660.00 2,700 1,000 3,700 3,500 200 3,000 1000 1,000 660,000 1000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - - - - 150 100 100 153,100 0
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 - 100 100 100 - - - - 100
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - - - - 100 100 100 30,400 0
190 Retinol/ Vit A 200.000 UI capsule 543.99 - - - - - - - - 0
191 Ringer Laktat 500 ml botol 7,630.00 - - - - - 100 100 100 763,000 0
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - - - - - 0
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 800 1,000 1,800 1,100 700 2,000 2000 2,000 126,000 1000
194 Salbutamol 2 mg tab tablet 67.00 - - - - - - - - 0
Page 276
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,600 1,000 2,600 1,400 1,200 2,000 - - 1000
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - - - - - - 0
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 41 20 61 34 27 50 33 33 146,718 20
198 pot 2,654.00 48 48 96 73 23 48 48 48 127,392 48
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 500 700 1,200 1,200 - 4,000 2000 2,000 2,420,000 700
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - - - - - - 0
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 345 - 345 253 92 200 200 200 581,400 0
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 2,010 - 2,010 840 1,170 2,000 - - 0
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 - 3,360 3,360 3,360 - 5,040 5040 5,040 589,680 3360
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 590 - 590 590 - 3,000 - - 0
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - - - - 5 5 5 66,010 0
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - - 5 5 5 95,965 0
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 1,300 - 1,300 600 700 2,000 - - 0
208 tablet 84.00 1,900 - 1,900 300 1,600 1,000 - - 0
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - 500 500 500 - - - - 500
tablet
210 salut 93.00 500 - 500 - 500 - - - 0
selaput
211 Vapril 25 mg tablet 193.00 600 1,500 2,100 2,100 - 3,000 3000 3,000 579,000 1500
212 box 6,550.00 10 - 10 - 10 - - - 0
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,400 1,000 2,400 2,100 300 5,000 1000 1,000 123,000 1000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 255 200 455 281 174 200 100 100 113,600 200
215 Vitamin B12 tablet 50 mcg tablet 52.00 1,800 3,000 4,800 4,800 - 3,000 3000 3,000 156,000 3000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - - - - - 0
217 Vitamin B6 10 mg tablet 138.00 - - - - - - - - 0
218 9,646.00 40 - 40 - 40 - - - 0
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 229 - 229 103 126 100 - - 0
OBAT GIZI (DAK 2019) - - - 0
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - - - - - 0
221 Hemafort tablet 834.90 1,300 3,600 4,900 4,800 100 7,200 7200 7,200 6,011,280 3600
Page 277
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 48 - 48 18 30 - - - 0
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - - - - - 0
224 Kapsul 581.00 - - - - - - - - 0
IU
BAHAN MEDIS HABIS PAKAI (DAK ) - - - 0
225 Allkohol 70% bottle 28,733.33 10 - 10 8 2 15 - - 0
226 Alkohol 70% 1L botol 28,750.00 3 - 3 3 - - - - 0
227 Arm sling L buah 17,424.00 2 - 2 - 2 - - - 0
228 Arm sling M buah 17,424.00 2 - 2 - 2 - - - 0
229 Arm sling S buah 17,424.00 2 - 2 - 2 - - - 0
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - - 30 - - 0
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 34 - 34 7 27 - - - 0
232 Aximed Syringe 1 cc Dus 103,750.00 - - - - - 3 3 3 311,250 0
233 Aximed Syringe 3 cc Dus 103,125.00 8 11 19 16 3 15 15 15 1,546,875 11
234 Blood Lancet box 16,022.60 4 2 6 3 3 5 - - 2
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 12 - 12 12 - 12 12 12 511,980 0
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 12 - 12 - 12 - - - 0
237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 - - - - - - - - 0
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 12 - 12 12 - 12 12 12 511,980 0
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 12 - 12 - 12 - - - 0
240 Catgut chromic 3/0 HR 30 mm Sachet 33,873.38 - - - - - - - - 0
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 12 - 12 1 11 - - - 0
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - - - - - - - - 0
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 12 - 12 - 12 - - - 0
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 - 12 12 12 - - - - 12
245 Catgut Plain 3/0 DS 19 mm Sachet 40,137.40 - - - - - - - - 0
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 12 60 72 69 3 - - - 60
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - - - - - - - 0
Page 278
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - - 100 50 50 476,256 0
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - - 100 50 50 476,256 0
253 Chirurgic Gloves, size 8 pcs 9,525.12 - - - - - 100 50 50 476,256 0
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 9 2 11 9 2 30 30 30 155,940 2
255 Dermafix T 10x12cm pcs 6,939.90 10 - 10 - 10 20 20 20 138,798 0
256 Examination Gloves size L box 58,564.00 2 5 7 7 - 5 5 5 292,820 5
257 Examination Gloves size M box 58,564.00 1 4 5 5 - 5 5 5 292,820 4
258 Examination Gloves size S box 58,564.00 4 2 6 6 - 5 5 5 292,820 2
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 25 4 29 18 11 10 10 10 374,400 4
260 Folley catheter 2 way no. 16 pcs 8,800.00 23 - 23 - 23 - - - 0
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 20 20 40 20 20 50 50 50 362,700 20
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - 50 - - 0
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - 50 - - 0
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - 50 - - 0
267 Hb Sahli set 96,800.00 - - - - - 3 - - 0
268 Hidrogen Peroxide 3% botol 3,864.00 5 - 5 - 5 - - - 0
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - - 2 2 2 197,232 0
270 Infuset pcs 6,166.16 16 30 46 44 2 50 50 50 308,308 30
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - - - - - - - 0
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 20 50 70 52 18 - - - 50
275 Kapas pembalut 250 gr roll 13,733.33 18 - 18 9 9 15 - - 0
276 Kapas pembalut 250 gr roll 13,750.00 5 5 10 5 5 15 15 15 206,250 5
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 8 9 17 17 - 50 - - 9
278 Kasa kompres steril 40 x 40 pcs 1,760.00 221 100 321 234 87 100 100 100 176,000 100
Page 279
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 200 - 200 25 175 - - - 0
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 50 - 50 - 50 - - - 0
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 10 10 20 20 - 50 - - 10
282 Lysol 1 liter botol 47,150.00 2 - 2 1 1 10 - - 0
283 Masker Ear Loop Box 20,202.00 - - - - - 20 - - 0
284 Masker Tie on Box 19,869.00 1 - 1 1 - - - - 0
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - - - - - 0
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - - - - - 0
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - - - - - - 0
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - - - - - 0
289 Onemed Alcohol Swab botol 11,000.00 11 - 11 1 10 - - - 0
290 Onemed Blood Lancet box 16,022.60 - - - - - - - - 0
291 Onesept 500 ml botol 30,360.00 16 - 16 16 - 20 - - 0
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 10 - 10 4 6 - - - 0
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - - - - - 0
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 6 - 6 2 4 - - - 0
295 Safeglove Examination Gloves L box 39,182.00 - - - - - - - - 0
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 10 5 15 12 3 50 - - 5
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - - - - - - 0
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 82 - 82 10 72 - - - 0
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - - - - - - 0
300 Stera Infuset anak pcs 3,850.00 37 - 37 8 29 20 - - 0
301 Surgical Mask Earloop box 18,150.00 - - - - - 20 - - 0
302 Surgical Mask Tie On box 18,150.00 - - - - - 20 - - 0
303 Swab 2 ply dus 14,040.84 - - - - - - - - 0
304 Syringe 10 cc dus 167,266.70 - - - - - 20 22 22 3,679,867 0
305 Syringe 1cc pcs 1,045.80 100 - 100 - 100 - - - 0
306 Syringe 1cc dus 106,523.56 - - - - - - - - 0
307 Syringe 3cc dus 107,421.38 - - - - - - - - 0
308 Syringe 5cc dus 119,090.61 2 - 2 - 2 - - - 0
Page 280
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - - - - - 0
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - - - - - 0
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - - - - - 0
312 Tp. Disposable Syringe 5 cc pcs 892.78 - - - - - - - - 0

313 pcs 7,072.50 - 50 50 50 - 20 20 20 141,450 50
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - - - - - 0
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - - - - - 0
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - - - - - 0
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 - - - - - - - - 0
318 Urine bag steril (t-valve) pcs 3,300.00 6 - 6 - 6 - - - 0
PEMERIKSAAN HIV - - - 0
319 HIV Device Box 707,143.00 - - - - - - - - 0
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS - - - 0
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - - - - - - - - 0
SUMBER DANA APBD I - - - 0
VAKSIN - - - 0
321 BCG +Pelarut BCG Vial 61,996.00 - - - - - - - - 0
322 Campak + Pelarut Campak Vial 28,204.00 - - - - - - - - 0
323 DPT-HB-Hib Vial 78,991.00 - - - - - - - - 0
324 DT Vial 17,996.00 - - - - - - - - 0
325 Hepatits B Buah 23,991.00 - - - - - - - - 0
326 IPV Vial 139,760.00 - - - - - - - - 0
327 IPV Vial 144,540.00 - - - - - - - - 0
328 MR Vial 141,648.00 - - - - - - - - 0
329 Polio+ Dropper Polio Vial 19,954.00 - - - - - - - - 0
330 Td Vial 16,995.00 - - - - - - - - 0
ANTI RABIES - - - 0
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - - - - - 0
OBAT FILARIASIS - - - 0
Page 281
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
332 Albendazol 400 mg tablet 258.74 - - - - - 200 - - 0
OBAT GIZI - - - 0
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - - - - - 0
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - - 0
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - - 0
OBAT MALARIA - - - 0
336 Blood Slide Kotak 18,509.00 - - - - - 0
337 DHP Frimal tablet 3,498.00 - - - - - 0
338 Kelambu GF Buah 61,077.00 - - - - - 0
339 Primaquin 15 mg tablet 235.00 - - - - - 0
OBAT KIA IBU - - - 0
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - 0
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - - 0
342 Euthyrox 50 mcg tablet 735.00 - - - - - 0
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 20 - 20 - 20 - - 0
344 Methylergometrin Injeksi ampul 3,102.00 100 - 100 45 55 - - 0
345 MgSO4 20 % fls 3,328.00 - - - - - 0
346 MgSO4 40 % fls 3,796.00 - - - - - 0
OBAT KIA ANAK - - - 0
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - 0
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - - 0
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 - 25 - 25 - - 0
OBAT TB PARU - - - 0
350 Box Slide Kotak 41,342.00 - - - - - 0
351 Kaca Slide Kotak 30,000.00 - - - - - 0
352 Kaca Slide Kotak 20,747.00 - - - - - 0
353 OAT Kategori Anak Paket 232,518.00 - - - - - 0
354 OAT Kategori I Paket 377,900.00 - - - - - 0
355 OAT Kategori II Paket 1,259,990.00 - - - - - 0
356 Pot Sputum Pot 2,500.00 - - - - - 0
Page 282
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
357 Reagen Ziehl Neelsen Kit 276,000.00 - - - - - 0
358 Sputum Pot Buah 2,950.00 - - - - - 0
359 Tuberkulin Vial 625,900.00 - - - - - 0
KUSTA - - - 0
360 MDT PB Dewasa Blister 12,569.00 - - - - - 0
ALAT DETEKSI RESIKO KEHAMILAN - - - 0
361 Paket ADRK II Paket 422,980.00 - - - - - 0
IMUNISASI - - - 0
362 ADS 0,05 ml Buah 1,518.00 - - - - - 0
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - - 0
364 ADS 0,5 ml Buah 1,127.00 - - - - - 0
365 ADS 0,5 ml Buah 1,090.00 - - - - - 0
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - - 0
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - 0
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - - 0
369 ADS 5 ml buah 1,705.00 - - - - - 0
370 ADS 5 ml Buah 1,705.00 - - - - - 0
371 ADS 5 ml Buah 1,439.00 - - - - - 0
372 ADS 5 ml Buah 1,500.00 - - - - - 0
373 RCW Unit 2,266,454.00 - - - - - 0
374 Safety Box pcs 16,608.00 - - - - - 0
375 Safety Box 2,5 ml Buah 12,500.00 - - - - - 0
376 Safety Box 5 ml Buah 20,394.00 - - - - - 0
377 Vaccine Carrier buah 1,870,000.00 - - - - - 0
OBAT FLU BURUNG - - - 0
378 Oseltamivir kapsul 12,969.00 - - - - - 0
OBAT DIARE - - - 0
379 Garam Oralit Sachet 257.00 - - - - - - - 0
380 Garam Oralit Sachet 253.00 221 - 221 58 163 - - 0
381 Zink Tablet tablet 551.00 1,000 - 1,000 200 800 - - 0
Page 283
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT HIV/AIDS - - - 0
382 Rapid 1 : SD HIV test 11,975.00 - - - - - 0
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - - 0
384 Rapid Sifilis Ab test 20,400.00 - - - - - 0
385 RPR Sifilis test 4,250.00 - - - - - 0
OBAT HEPATITIS - - - 0
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - - 0
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - - 0
Reagensia/ Alat - - - 0
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - - - 0
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - - 0
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - - 0
391 Rapid 3 Diagnostar test 13,771.00 - - - - - 0
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - - 0
393 Rapid Sifilis Trepocheck test 9,697.00 - - - - - 0
394 RPR Sifilis test 4,250.00 - - - - - 0
SUMBER DANA APBD II - - - 0
OBAT KATARAK - - - 0
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - - - 0
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - - - 0
OBAT PROGRAM - - - 0
397 L- Zinc botol 31,350.00 - - - - - 0
398 Lagesil Suspensi botol 40,755.00 - - - - - - - 0
REAGENTIA - - - 0
399 Objek Gelas Kotak 50,000.00 - - - - - 0
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - - 0
REAGENSIA - - - 0
401 Larutan Alkohol 96% botol 242,000.00 - - - - - 0
402 Larutan Metanol botol 665,500.00 - - - - - 0
403 Reagen Benedict botol 484,000.00 - - - - - 0
Page 284
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
404 Reagen Natrium Sitrat botol 514,250.00 - - - - - 0
405 Reagen Receker botol 2,238,500.00 - - - - - 0
406 Reagensia Asam Asetat botol 544,500.00 - - - - - 0
407 Slide test widal Unit 302,500.00 - - - - - 0
BELANJA STICK NARKOBA - - - 0
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - - 0
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - - 0
PENINGKATAN KESEHATAN MASYARAKAT - - - 0
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - - - 0
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - - 0
DHP Frimal Box 2,134.00 9 - 9 - 9 - - 0
Lysol 1 liter botol 82,150.00 40 40 100 100 100 8,215,000
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1000 1000 1,000 1000 1,000 110,000
Masker box 450,000.00 5 5 20 20 20 9,000,000
Alkohol 300 ml Bottle 80,000.00 20 20 10 10 10 800,000
One Med Povidone Iodine 30 ml botol 3,680.00 25 25 20 20 20 73,600
Alkohol 70% 1L botol 230,000.00 2 2 15 15 15 3,450,000
Biosat 1,5 Serum antitetanus (A.T.S) inj 1500 Ampul 130,999.00 2 2 2 261,998
IU/amp (i.m)
TOTAL 78,883,024

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr. Hj.Iin Herliani Sariaini Lukfi Tanjung, Amk
Page 285
DINKES
PUSKESMAS : TANJUNG LEIDONG LAPORAN TRIWULAN : I II (III) IV GFK 6/IFK/3/2020 11-Aug-20
KECAMATAN : KUALUH LEIDONG PERMINTAAN TRIWULAN : I II III (IV (IV) PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 1,000
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 400
3 Alopurinol tablet 100 mg tablet 97.00 200 10,000
4 Alopurinol tablet 100 mg tablet 104.00 -
5 Ambroxol 15 mg/5 ml botol 6,600.00 56 12 300
6 Ambroxol tab 30 mg tablet 330.00 800 200 10,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 788
8 Aminofilin tablet 200 mg tablet 92.00 1,400
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 1,200 1,200
10 Amlodipine Besilat tablet 5 mg tablet 73.00
11 tablet 78.00 - 900 - 5,000
12 Kaplet 94.00 4,800 200 6,000
13 Amoksisilin 100 mg/mL botol 13,500.00 12
14 Amoksisilin 250 mg kapsul Kapsul 203.00 300
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 6 14 300
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 26 200
17 kaptab 261.00 200 20,000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 70
19 Antasida Tablet box 5,594.00 -
20 Antasida Tablet tablet 200.00
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
21 Antasida Tab Tablet 355.00 1,200 1,200 10,000

22 tablet 60.00 -
23 botol 2,189.00 29 300

+ Polimiksin 10.000
3,071.00
IU/g - 200

25 pot 4,540.00 48
Asam Salisilat 3%

26 3,325.00 -
heksaklorofen ria
27 Arkine 100 tablet 687.50 -
28 Asam Mefenamat 500 mg tablet 242.89 -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - 20
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 300
31 Asiklovir Tablet 200 mg Tablet 560.18 -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 55
33 Bedak salisil serbuk 2% dus 1,040.00 5 100
34 Bedak Salisil Kotak 8,000.00 - 6 100
35 Betametason krim 0,5 mg/g tube 3,388.00 200
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - 100
37 Ampul 130,999.00 1 10
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 1 2
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 600
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 92 288
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 -
43 Cefotaxime sodium 1 gr vial 7,342.50 -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
46 Cetirizin Hydrochloride salut 94.00 -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 5,000
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 12 250
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 -
tablet
50 salut 165.00 -
selaput
51 kapsul 770.00 2,100 5,000
52 Codeine 10 mg tablet 600.00 140 500
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 100 200

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 1,100 5,000
56 tablet 47.00 -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 - 500
mg/ml
58 Dexamethason inj Ampul 4,500.00

59 Dexametason Tablet 0,5 mg Tablet 33.00 5,600 20,000
60 Dexamethasone tablet 0,5 mg tablet 154.00 -
61 Dekstrofen Syrup Botol 11,550.00 - 200
62 Diazepam 2 mg Tablet 86.00 200
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 10 10
65 Diclofenac Sodium 25 mg Tablet 141.00 -
66 Diclofenac Sodium 50 mg Tablet 136.00 - 5,600
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 -
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 -

69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 -
70 Digoksin tablet 0,25 mg tablet 106.00 -
71 Digoksin 0,25 mg Tablet 104.00 500
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 - 300
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 -
75 Domperidon tablet 10 mg tablet 86.00 900 5,000
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 10
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - 10
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 100 200 1,200
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - 1,000
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 6 100
83 Eugenol cairan botol 21,091.00 -
84 Fenobarbital tablet 30 mg tablet 165.00 600 500
85 Fenobarbital tablet 30 mg tablet 180.00 -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - 72
87 tablet 747.00 -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 - 3,000
89 ampul 3,867.00 120
mg/ml
90 Fituno Tab tablet 4,163.10 - 300
91 Furosemid Inj 10 mg/ml ampul 1,333.00 130
92 Furosemide tablet 40 mg tablet 77.00 - 1,000
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 48

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - 72
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 5,000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 40
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 300 5,000
99 Griseofulvin tablet 125 mg tablet 232.00 -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 -
101 Haloperidol 0,5 mg Tablet 55.00 -
102 Hidroklorotiazid tab 25 mg tablet 163.00
103 Hidrokortison krim 2,5 % tube 2,640.00 - 200
104 Hidrokortison krim 2,5% tube 2,475.00 -
105 Hustab Syrup botol 11,550.00 - 300
106 Hustab P Tablet 8 mg Tablet 256.67 1,500 6,600
107 Hustab Tablet tablet 437.00 1,800 3,300 10,800
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 2,100 10,000
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 -
selaput
110 Ibuprofen 200 mg Tablet 550.00 -
111 Ibuprofen 400 mg Tablet 800.00 3,000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - 3,000
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 800
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - 1,000

116 tablet 63.00 - 800 5,000
117 Kanamycin 1 gr inj vial 10,768.00 -
118 Kaptopril 12,5 mg tablet 68.00 -
119 Ketokenazol tablet 200 mg tablet 278.00 -
120 Ketokonazol tablet 200 mg tablet 297.00 - 5,000
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
121 Kloramfenicol kapsul 250 mg Capsule 320.00

122 Kloramfenikol kapsul 250 mg Kapsul 660.00 -
123 Kloramfenikol Salep 2% tube 3,349.00 -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 - 48
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 6
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 -
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 2,100
129 Klorfeniramin maleat tablet 25.00 - 2,100 19,800
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 540 3,000
131 Lansoprazole kapsul 30 mg kapsul 1,283.75
132 Lidocaine Injeksi 2 % ampul 1,203.00 -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 - 5,000
134 Meloksikam 7,5 mg tablet 795.68 -
135 Meloxicam tab15 mg tablet 1,438.80 - 5,000
136 Meloxicam 15 mg Tablet 980.00 -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 - 5,000
138 tablet 137.00 -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - 8,000
140 Methylprednisolone tablet 4 mg tablet 528.66 -

141 Methyl prednisolone 125 mg Dos 8,143.00 -
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 200 800
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 6 50
146 Metronidazole tablet 500 mg tablet 264.00 200 5,000
147 MgSO4 20 % botol 13,500.00 16
148 MgSO4 40 % botol 13,500.00 20
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 - 96

150 NaCl 0,9 % 500 ml botol 6,840.00 100
151 tablet 132.00
25 mg
152 tablet 127.00 -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 3,200 5,000
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 -
155 Nystatin tablet 500.000 IU Tablet 886.00 -
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - 16
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 -
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 1
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 -
161 Omeprazol Tab Tablet 650.00 900
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - 200
163 Paracetamol Tab 500 mg tablet 290.00 -
164 Paracetamol kaplet 500 mg kaplet 165.00 2,400 1,400 10,400
165 bottle 6,981.00 -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - 300
167 Pehacain Injeksi ampul 3,113.06 -
168 Pehacain Injeksi Ampul 3,113.05 -
169 Pehamoksil Tablet 500 mg Tablet 759.00 -
170 Pehastan 500 mg tablet 445.50 - 7,200
171 Pehavral tablet 935.00 - 5,000
172 Perak sulfadiazin krim 1% tube 20,700.00 50
173 Peridol Syrup 60 ml botol 19,800.00 - 92
174 botol 124,355.00
0,2 %
175 Phaproxin 500 mg tablet 880.00 1,600 3,000
176 tablet 302.00 -
mg
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
177 Pirantel pamoat 125 mg tab tablet 322.00 300

178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 -
179 Pirantel Pamoat syrup botol 10,778.00 2
180 Tablet 124.00 -
(HCl)
181 tablet 129.00 - 2,100 7,000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 300 5,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 -
184 Pularex Attapulgit tab 630 mg tablet 142.00
185 Pyridol Syrup 60 ml botol 18,150.00 -
186 Ranitidin 150 mg Tablet tablet 660.00 - 10,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 - 500
189 Retinol/ Vit A 100.000 UI capsule 304.00 -
190 Retinol/ Vit A 200.000 UI capsule 543.99 -
191 Ringer Laktat 500 ml botol 7,630.00 32 500
192 Roeko Endo Frost 200 ml botol 352,000.00 -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 200 5,000
194 Salbutamol 2 mg tab tablet 67.00 -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 5,000
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 96
198 pot 2,654.00 12
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - 5,000
200 Seftriakson serb inj 1.000 mg vial 4,998.00 34
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 360 6,720
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 5
206 Stesolid 10 mg/2,5 ml tube 19,193.00 -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 - 1,000
208 tablet 84.00 -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 600 3,000
tablet
210 salut 93.00 -
selaput
211 Vapril 25 mg tablet 193.00 5,000
212 box 6,550.00 -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,100 1,000

214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 - 1,500
215 Vitamin B12 tablet 50 mcg tablet 52.00 1,800 5,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 -
217 Vitamin B6 10 mg tablet 138.00 -
218 9,646.00 - 10
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - 100
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 -

221 Hemafort tablet 834.90 1,000 10,800
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 -
224 Kapsul 581.00 -
IU
225 Allkohol 70% bottle 28,733.33 - 24

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
226 Alkohol 70% 1L botol 28,750.00 -
227 Arm sling L buah 17,424.00 -
228 Arm sling M buah 17,424.00 -
229 Arm sling S buah 17,424.00 -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 -
232 Aximed Syringe 1 cc Dus 103,750.00 -
233 Aximed Syringe 3 cc Dus 103,125.00 4 1,000
234 Blood Lancet box 16,022.60 - 2,000
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 12 48
237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 -
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 12 48
240 Catgut chromic 3/0 HR 30 mm Sachet 33,873.38 -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 12 48
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 12 48
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00
245 Catgut Plain 3/0 DS 19 mm Sachet 40,137.40 -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 12
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 100
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - 200
251 Chirurgic Gloves, size 7 pcs 9,525.12 - 100
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - 100

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
253 Chirurgic Gloves, size 8 pcs 9,525.12 - 100
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 20
255 Dermafix T 10x12cm pcs 6,939.90 - 50
256 Examination Gloves size L box 58,564.00 - 10
257 Examination Gloves size M box 58,564.00 - 10
258 Examination Gloves size S box 58,564.00 - 10
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - 5
260 Folley catheter 2 way no. 16 pcs 8,800.00 3 10
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 -
264 Gynaecologycal Glove, Large pcs 40,733.00 -
265 Gynaecologycal Glove, Medium pcs 40,733.00 -
266 Gynaecologycal Glove, Small pcs 40,733.00 -
267 Hb Sahli set 96,800.00 1
268 Hidrogen Peroxide 3% botol 3,864.00 - 5
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 -
270 Infuset pcs 6,166.16 32 100
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 -
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 - 100
273 IV- Cath WP, with wings & port no 24 pcs 8,088.85 - 100
274 IV- Cath WP, with wings & port no 26 pcs 10,477.39 12 100
275 Kapas pembalut 250 gr roll 13,733.33 - 10
276 Kapas pembalut 250 gr roll 13,750.00 10
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 50
278 Kasa kompres steril 40 x 40 pcs 1,760.00 - 200
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 100

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 100
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 -
282 Lysol 1 liter botol 47,150.00 - 24
283 Masker Ear Loop Box 20,202.00 - 10
284 Masker Tie on Box 19,869.00 - 10
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 4
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 6
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 4 10
289 Onemed Alcohol Swab botol 11,000.00 - 50
290 Onemed Blood Lancet box 16,022.60 -
291 Onesept 500 ml botol 30,360.00 - 10
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00
295 Safeglove Examination Gloves L box 39,182.00 -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 3
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 12 24
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 12
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 12
300 Stera Infuset anak pcs 3,850.00 -
301 Surgical Mask Earloop box 18,150.00 - 50
302 Surgical Mask Tie On box 18,150.00 - 30
303 Swab 2 ply dus 14,040.84 -
304 Syringe 10 cc dus 167,266.70
305 Syringe 1cc pcs 1,045.80
306 Syringe 1cc dus 106,523.56 -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
307 Syringe 3cc dus 107,421.38 -
308 Syringe 5cc dus 119,090.61 1
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 -
311 TP. Disposable Syringe 3 cc pcs 750.39 -
312 Tp. Disposable Syringe 5 cc pcs 892.78 -

313 pcs 7,072.50 50
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 -
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 -
318 Urine bag steril (t-valve) pcs 3,300.00 -
PEMERIKSAAN HIV
319 HIV Device Box 707,143.00 -
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 -
SUMBER DANA APBD I
VAKSIN
321 BCG +Pelarut BCG Vial 61,996.00 -
322 Campak + Pelarut Campak Vial 28,204.00 -
323 DPT-HB-Hib Vial 78,991.00 -
324 DT Vial 17,996.00 -
325 Hepatits B Buah 23,991.00 -
326 IPV Vial 139,760.00 -
327 IPV Vial 144,540.00 -
328 MR Vial 141,648.00 -
329 Polio+ Dropper Polio Vial 19,954.00 -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
330 Td Vial 16,995.00 -
ANTI RABIES
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 -
OBAT FILARIASIS
332 Albendazol 400 mg tablet 258.74 -
OBAT GIZI
333 Tablet Tambah Darah (Rematri) tablet 372.00 -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 -
OBAT MALARIA
336 Blood Slide Kotak 18,509.00 -
337 DHP Frimal tablet 3,498.00 - 50
338 Kelambu GF Buah 61,077.00 -
339 Primaquin 15 mg tablet 235.00 - 300
OBAT KIA IBU
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 -
341 Ca. Glukonas Injeksi ampul 10,351.00 -
342 Euthyrox 50 mcg tablet 735.00 -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 -
344 Methylergometrin Injeksi ampul 3,102.00 -
345 MgSO4 20 % fls 3,328.00 -
346 MgSO4 40 % fls 3,796.00 -
OBAT KIA ANAK
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 -
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 -
OBAT TB PARU
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
350 Box Slide Kotak 41,342.00 -
351 Kaca Slide Kotak 30,000.00 10
352 Kaca Slide Kotak 20,747.00 -
353 OAT Kategori Anak Paket 232,518.00 -
354 OAT Kategori I Paket 377,900.00 - 10
355 OAT Kategori II Paket 1,259,990.00 -
356 Pot Sputum Pot 2,500.00 -
357 Reagen Ziehl Neelsen Kit 276,000.00
358 Sputum Pot Buah 2,950.00
359 Tuberkulin Vial 625,900.00 -
KUSTA
360 MDT PB Dewasa Blister 12,569.00 - 1
361 Paket ADRK II Paket 422,980.00 -
IMUNISASI
362 ADS 0,05 ml Buah 1,518.00 -
363 ADS 0,5 (Oneject) Buah 1,621.00 -
364 ADS 0,5 ml Buah 1,127.00 -
365 ADS 0,5 ml Buah 1,090.00 -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 -
367 ADS 0,5 ml SKIFA buah 1,240.00 -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 -
369 ADS 5 ml buah 1,705.00 -
370 ADS 5 ml Buah 1,705.00 -
371 ADS 5 ml Buah 1,439.00 -
372 ADS 5 ml Buah 1,500.00 -
373 RCW Unit 2,266,454.00 -

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
374 Safety Box pcs 16,608.00 -
375 Safety Box 2,5 ml Buah 12,500.00 -
376 Safety Box 5 ml Buah 20,394.00 -
377 Vaccine Carrier buah 1,870,000.00 -
OBAT FLU BURUNG
378 Oseltamivir kapsul 12,969.00 -
OBAT DIARE
379 Garam Oralit Sachet 257.00
380 Garam Oralit Sachet 253.00 23 500
381 Zink Tablet tablet 551.00 300 1,000
OBAT HIV/AIDS
382 Rapid 1 : SD HIV test 11,975.00 -
383 Rapid 2 : Focus Diagnostic test 13,615.00 -
384 Rapid Sifilis Ab test 20,400.00 -
385 RPR Sifilis test 4,250.00 -
OBAT HEPATITIS
386 HB Imuno Globulin Kotak 1,325,000.00 -
387 Rapid Test SD Bioline HBsAg test 9,870.00 -
Reagensia/ Alat
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 -
389 Rapid 2 HIV (Focus) test 13,615.00 -
390 Rapid 2 HIV (KHB) test 12,500.00 -
391 Rapid 3 Diagnostar test 13,771.00 -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 -
393 Rapid Sifilis Trepocheck test 9,697.00 -
394 RPR Sifilis test 4,250.00 -
SUMBER DANA APBD II

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT KATARAK
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - 100
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - 50
OBAT PROGRAM
397 L- Zinc botol 31,350.00 - 10
398 Lagesil Suspensi botol 40,755.00 - 20
REAGENTIA
399 Objek Gelas Kotak 50,000.00 -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 -
REAGENSIA
401 Larutan Alkohol 96% botol 242,000.00 -
402 Larutan Metanol botol 665,500.00 -
403 Reagen Benedict botol 484,000.00 -
404 Reagen Natrium Sitrat botol 514,250.00 -
405 Reagen Receker botol 2,238,500.00 -
406 Reagensia Asam Asetat botol 544,500.00 -
407 Slide test widal Unit 302,500.00 -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 -
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - 10
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - 10
OAT Kombipak Kategori 1 Paket 317,018.00 3 16
Lysol 1 liter botol 82,150.00 12 60
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 20,000
Masker box 450,000.00 50
DHP Frimal TAblet 2,134.00 50
One Med Povidone Iodine 30 ml botol 3,680.00 100

JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Alkohol 70% 1L botol 230,000.00 20
TOTAL -

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Dewi Daulay, SKM Qomariah Habibi
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 19770502 200801 2 002 Nip. 19850921 200903 2 011
-
-
-
-
300
5,000
-
-
-
-
3,000
6,000
-
5,000
100
240
10,000
-
-
-
10,000
300
75
-
-
-
500
-
-
100
-
72
-
150
-
120
-
-
-
-
-
1,500
100
-
4,800
-
-
200
2,000
240
-
19,800
-
200
-
-
-
-
-
-
780
-
-
500
-
150
-
5,000
-
-
-
-
40
-
-
-
24
500
60
90
-
200
-
-
24
3,000
2,000
-
-
-
-
-
-
100
6,000
7,200
8,600
-
-
50
150
3,000
-
3,000
-
300
-
700
-
48
50
-
-
-
-
2,720
-
-
1,500
-
2,000
-
8,000
-
-
-
-
-
700
-
2,000
-
-
96
-
-
-
300
-
-
-
-
-
600
-
-
10,400
100
-
1,240
-
7,200
2,000
-
24
3,600
-
400
-
-
3,000
2,000
-
-
-
11,500
-
300
-
-
500
-
2,000
-
2,000
-
-
2,000
-
-
3,360
-
-
-
300
5,000
9,400
1,500
10,000
-
-
-
-
-
7,200
-
-
-
-
-
-
-
-
20
-
-
48
-
-
-
-
-
-
-
-
-
-
-
-
-
50
50
50
50
-
50
5
10
5
10
10
-
-
-
-
-
-
-
5
-
100
-
100
50
20
-
-
-
200
100
50
-
-
-
-
-
10
10
10
10
-
-
-
20
-
-
30
-
-
-
-
5
20
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
200
10
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
PUSKESMAS MARBAU TAHUN 2020
DINKES
PUSKESMAS : Marbau LAPORAN TRIWULAN : I (II) III IV GFK 5/GFK/3/2020 10-Aug-20
KECAMATAN : Marbau PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
HARGA STOK PENERI SISA STOK PERMIN
NO NAMA OBAT SATUAN PERSEDIAAN PEMAKAIAN
SATUAN (Rp) AWAL MAAN STOK OPT TAAN TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Acetyl cysteine/ N-Asetil sistein tablet/kaplet/kapsul 200

1 capsule 357.00 - - - - 0
mg
2 Acyclovir 200 mg Tablet 1,050.00 - - - - 0
3 Alopurinol tablet 100 mg tablet 97.00 2,714 5,000 7,714 5,491 2,223 5,000 2,000 2,000 194,000.00 3,000
4 Alopurinol tablet 100 mg tablet 104.00 - - - - 0
5 Ambroxol 15 mg/5 ml botol 6,600.00 100 100 2 98 100 100 100 660,000.00 100
6 Ambroxol tab 30 mg tablet 330.00 - - - - 0
7 Aminofilin inj 24 mg/ml ampul 2,998.00 90 90 180 125 55 - - 0
8 Aminofilin tablet 200 mg tablet 92.00 400 400 800 700 100 - - 400
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 520 520 95 425 - - 0
10 Amlodipine Besilat tablet 5 mg tablet 73.00 1,100 3,000 4,100 3,810 290 3,000 - - 0
11 tablet 78.00 2,100 2,100 2,100 900 900 900 70,200.00 2,100
12 Kaplet 94.00 - - 300 300 300 28,200.00 0
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - 0
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - - - 0
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 133 100 233 113 120 100 100 100 660,000.00 100
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 100 100 - 100 - - 100
Amoksisilin/Amoxicillin tablet/kapsul/kaplet/kaptab 500
17 kaptab 261.00 3,815 7,000 10,815 5,397 5,418 7,000 5,000 5,000 1,305,000.00 7,000
mg, kemasan strip/blister (G)
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - 0
19 Antasida Tablet box 5,594.00 - - - - 0
20 Antasida Tablet tablet 200.00 2,913 7,000 9,913 6,111 3,802 7,000 - - 7,000
21 Antasida Tab Tablet 355.00 - - 5,000 5,000 5,000 1,775,000.00 0
22 tablet 60.00 - - - - 0
23 botol 2,189.00 161 161 83 78 150 150 150 328,350.00 0
Page 321
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
24 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g +tube
Polimiksin 10.000 3,071.00
IU/g 17 17 1 16 - - 0

25 pot 4,540.00 9 9 9 - - 0
Asam Salisilat 3%
26 3,325.00 17 30 47 5 42 30 30 30 99,750.00 30
heksaklorofen a
27 Arkine 100 tablet 687.50 - - - - 0
28 Asam Mefenamat 500 mg tablet 242.89 - - 3,000 - - 0
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 23 23 - 23 - - 0
Page 322
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 1,000 500 1,500 382 1,118 1,000 1,000 1,000 245,000.00 500
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - 0
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - - - - 0
33 Bedak salisil serbuk 2% dus 1,040.00 30 30 12 18 30 - - 30
34 Bedak Salisil Kotak 8,000.00 - - 20 20 20 160,000.00 0
35 Betametason krim 0,5 mg/g tube 3,388.00 33 20 53 53 50 - - 20
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 25 25 12 13 50 50 50 67,000.00 25
37 Ampul 130,999.00 1 1 1 1 - - 0
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 1 1 - 1 1 1 1 512,204.00 0
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - - 500 120 120 39,240.00 0
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 78 78 71 7 - - 0
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 24 24 - 24 72 72 72 225,936.00 0
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - - 0
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - 0
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - 50 - - 0
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - 0
tablet salut
46 Cetirizin Hydrochloride 94.00 - - 5,000 - - 0
selaput
47 Cetirizine tablet 10 mg tablet 101.00 1,500 1,500 1,302 198 1,000 1,000 1,000 101,000.00 1,500
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 44 44 25 19 50 50 50 148,650.00 0
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - 0

50 165.00 - - - - 0
51 kapsul 770.00 1,525 1,525 810 715 2,000 2,000 2,000 1,540,000.00 0
52 Codeine 10 mg tablet 600.00 180 180 - 180 - - 0
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - 51 51 50 - - 0
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 44 44 44 50 50 50 109,500.00 0
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 mg tablet 133.00 614 700 1,314 415 899 2,000 500 500 66,500.00 700
(tab/kaptab 480 mg)
56 tablet 47.00 - - - - 0
Page 323
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Deksametason sodium
57 ampul 1,152.00 215 240 455 146 309 200 50 50 57,600.00 240
phosphate/Dexamethasone/Deksametason injeksi 5 mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - - 0

59 Dexametason Tablet 0,5 mg Tablet 33.00 5,000 3,000 8,000 4,645 3,355 5,000 5,000 5,000 165,000.00 3,000
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - 0
61 Dekstrofen Syrup Botol 11,550.00 96 100 196 91 105 50 - - 100
62 Diazepam 2 mg Tablet 86.00 125 200 325 123 202 300 300 300 25,800.00 0
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - 0
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 7 7 2 5 - - 0
65 Diclofenac Sodium 25 mg Tablet 141.00 - - 2,800 2,800 2,800 394,800.00 0
66 Diclofenac Sodium 50 mg Tablet 136.00 - - 5,600 5,600 5,600 761,600.00 0
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 100 100 100 - - 0
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 90 90 25 65 120 120 120 138,120.00 90
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - 0
70 Digoksin tablet 0,25 mg tablet 106.00 - - 200 200 200 21,200.00 0
71 Digoksin 0,25 mg Tablet 104.00 200 200 52 148 - - 200
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 582 582 582 - - 0
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 63 100 163 82 81 100 100 100 278,100.00 100
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 1,148 1,148 1,148 5,000 1,000 1,000 95,000.00 0
75 Domperidon tablet 10 mg tablet 86.00 4,000 4,000 2,227 1,773 - - 4,000
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - - 36 30 30 177,000.00 0
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 12 12 3 9 - - 0
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 118 118 118 - - 0
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 10 10 20 10 10 - - 0
kaptab
80 Eritromisin kapl 500 mg salut 765.00 1,238 1,000 2,238 1,353 885 2,000 2,000 2,000 1,530,000.00 1,000
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - 0
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 - - - - 0
83 Eugenol cairan botol 21,091.00 1 1 - 1 - - 0
84 Fenobarbital tablet 30 mg tablet 165.00 200 200 - 200 - - 0
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - 0
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - - 0
87 tablet 747.00 - - - - 0
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 695 500 1,195 635 560 1,000 1,000 1,000 797,000.00 500
Page 324
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
89 ampul 3,867.00 37 37 19 18 - - 0
mg/ml
90 Fituno Tab tablet 4,163.10 - - - - 0
91 Furosemid Inj 10 mg/ml ampul 1,333.00 10 10 10 25 25 25 33,325.00 10
92 Furosemide tablet 40 mg tablet 77.00 4,826 1,000 5,826 5,641 185 1,000 - - 0
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - 0
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 24 24 6 18 50 - - 24
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 24 24 4 20 50 - - 24
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 2,591 3,000 5,591 3,021 2,570 5,000 2,000 2,000 250,000.00 3,000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 30 30 2 28 - - 0
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 400 1,000 1,400 552 848 1,000 500 500 122,500.00 1,000
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - 0

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - 0
101 Haloperidol 0,5 mg Tablet 55.00 639 639 274 365 500 500 500 27,500.00 0
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - - 0
103 Hidrokortison krim 2,5 % tube 2,640.00 37 48 85 68 17 48 48 48 126,720.00 48
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - 0
105 Hustab Syrup botol 11,550.00 117 100 217 95 122 100 100 100 1,155,000.00 100
106 Hustab P Tablet 8 mg Tablet 256.67 900 3,000 3,900 2,696 1,204 3,000 3,000 3,000 770,010.00 3,000
107 Hustab Tablet tablet 437.00 - - 3,600 3,600 3,600 1,573,200.00 0
tablet salut
108 Ibuprofen tab/kaps/kapl 200 mg 108.00 2,000 2,000 1,200 800 - - 2,000
selaput
tablet salut
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg 105.00 480 480 480 2,000 600 600 63,000.00 0
selaput
110 Ibuprofen 200 mg Tablet 550.00 - - - - 0
111 Ibuprofen 400 mg Tablet 800.00 1,000 1,000 2,000 200 1,800 3,000 500 500 400,000.00 1,000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 - - - - 0
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 100 100 59 41 100 50 50 138,800.00 100
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - - 500 500 500 44,500.00 0
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - - 0

116 tablet 63.00 1,385 3,000 4,385 1,045 3,340 5,000 1,000 1,000 63,000.00 3,000
117 Kanamycin 1 gr inj vial 10,768.00 - - - - 0
118 Kaptopril 12,5 mg tablet 68.00 300 300 - 300 - - 300
119 Ketokenazol tablet 200 mg tablet 278.00 - - - - 0
Page 325
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
120 Ketokonazol tablet 200 mg tablet 297.00 700 700 455 245 2,000 - - 700
121 Kloramfenicol kapsul 250 mg Capsule 320.00 2,150 2,150 1,370 780 1,000 - - 0
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 700 700 - 700 2,000 600 600 396,000.00 700
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - 0
124 Kloramfenikol salep mata 1 % Tube 2,007.00 31 24 55 12 43 24 24 24 48,168.00 24
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 112 150 262 109 153 50 - - 150
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - 100 100 100 516,800.00 0
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 1,300 2,800 4,100 4,100 3,000 - - 2,800
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - 0
129 Klorfeniramin maleat tablet 25.00 - - 3,000 3,000 3,000 75,000.00 0
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 1,024 1,024 1,024 3,000 1,000 1,000 303,000.00 0
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 900 900 900 - - 900
132 Lidocaine Injeksi 2 % ampul 1,203.00 20 20 - 20 - - 0
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 1,447 1,000 2,447 1,087 1,360 1,000 500 500 130,000.00 1,000
134 Meloksikam 7,5 mg tablet 795.68 - - 2,000 - - 0
135 Meloxicam tab15 mg tablet 1,438.80 665 665 665 1,000 1,000 1,000 1,438,800.00 0
136 Meloxicam 15 mg Tablet 980.00 - - - - 0
tablet salut
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan strip/blister 106.00 190 500 690 490 200 3,000 300 300 31,800.00 500
selaput
(G)
138 Metilprednisolon/methylprednisolone tab/kaps/kapl 4 mg tablet 137.00 2,400 2,400 1,873 527 5,000 - - 3,000
139 Metilprednisolon tablet 4 mg tablet 146.00 - - 2,000 2,000 2,000 292,000.00 0
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - 0
141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - 0

tablet salut
142 Metil Ergometrin tablet Salut Selaput 0,125 mg 222.00 500 500 40 460 - - 0
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - 0
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 - - - - 0
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 49 49 - 49 - - 0
146 Metronidazole tablet 500 mg tablet 264.00 200 2,000 2,200 1,335 865 3,000 700 700 184,800.00 2,000
147 MgSO4 20 % botol 13,500.00 12 12 - 12 - - 0
148 MgSO4 40 % botol 13,500.00 12 12 - 12 - - 0
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 27 48 75 41 34 48 48 48 172,080.00 48
150 NaCl 0,9 % 500 ml botol 6,840.00 80 60 140 47 93 100 100 100 684,000.00 60
Natrium Diklofenak tablet/kapsul/kaplet salit enterik 25
151 tablet 132.00 2,800 2,800 2,800 5,000 - - 0
mg
Page 326
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Natrium Diklofenak tablet/kapsul/kaplet salit enterik 50
152 tablet 127.00 2,300 2,800 5,100 762 4,338 - - 2,300
mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 3,000 3,000 30 2,970 - - 0
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 - - - - 0
155 Nystatin tablet 500.000 IU Tablet 886.00 - - - - 0
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - - 0
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - 0
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - - 0
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - - 0
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - - 0
161 Omeprazol Tab Tablet 650.00 - - 2,000 200 200 130,000.00 0
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 40 40 28 12 100 - - 0
163 Paracetamol Tab 500 mg tablet 290.00 3,372 3,372 3,372 7,000 - - 0
164 Paracetamol kaplet 500 mg kaplet 165.00 6,000 6,000 2,776 3,224 10,400 10,400 10,400 1,716,000.00 6,000
165 bottle 6,981.00 - - 20 - - 0
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 20 50 70 46 24 200 50 50 59,200.00 50
167 Pehacain Injeksi ampul 3,113.06 71 71 64 7 - - 0
168 Pehacain Injeksi Ampul 3,113.05 70 300 370 96 274 100 100 100 311,305.00 100
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - 5,000 - - 0
170 Pehastan 500 mg tablet 445.50 3,000 3,000 2,564 436 5,000 3,000 3,000 1,336,500.00 3,000
171 Pehavral tablet 935.00 1,438 2,100 3,538 2,836 702 3,000 - - 2,100
172 Perak sulfadiazin krim 1% tube 20,700.00 7 10 17 8 9 10 - - 10
173 Peridol Syrup 60 ml botol 19,800.00 - - - - 0
Perio Kin Spray Chlorhexidin Gluconat/ Klorheksidin 0,2
174 botol 124,355.00 - - - - 0
%
175 Phaproxin 500 mg tablet 880.00 200 100 300 300 2,000 1,800 1,800 1,584,000.00 100
176 Pirantel pamoat / pyrantel pamoate tab/kaps/kapl 125 mg tablet 302.00 - - - - 0
177 Pirantel pamoat 125 mg tab tablet 322.00 100 100 84 16 100 100 100 32,200.00 100
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 1 5 6 1 5 10 - - 5
179 Pirantel Pamoat syrup botol 10,778.00 - - - - 0
180 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 124.00 - - - - 0
181 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) tablet 129.00 2,161 1,000 3,161 2,861 300 3,000 2,000 2,000 258,000.00 1,000
182 Prednison tablet 5 mg tablet 76.00 2,000 2,000 1,437 563 2,000 2,000 2,000 152,000.00 2,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 411 411 411 5,000 - - 0
184 Pularex Attapulgit tab 630 mg tablet 142.00 510 500 1,010 590 420 1,000 300 300 42,600.00 500
185 Pyridol Syrup 60 ml botol 18,150.00 72 72 144 96 48 - - 0
Page 327
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
186 Ranitidin 150 mg Tablet tablet 660.00 2,057 4,000 6,057 6,057 8,000 2,000 2,000 1,320,000.00 4,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 306 306 306 - - 0
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 200 200 - 200 300 100 100 115,500.00 200
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - - - 0
191 Ringer Laktat 500 ml botol 7,630.00 218 150 368 150 218 500 500 500 3,815,000.00 150
192 Roeko Endo Frost 200 ml botol 352,000.00 4 4 - 4 - - 4
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 500 500 - 500 - - 500
194 Salbutamol 2 mg tab tablet 67.00 - - - - 0
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,290 1,290 1,170 120 2,000 1,500 1,500 120,000.00 0
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - - 0
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - 40 40 40 177,840.00 0
Salep 2-4, kombinasi: asam salisilat 2% + belerang endap
198 pot 2,654.00 18 48 66 31 35 48 48 48 127,392.00 48
4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 440 500 940 940 2,000 700 700 847,000.00 500
200 Seftriakson serb inj 1.000 mg vial 4,998.00 50 50 - 50 20 20 20 99,960.00 50
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - - 0
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 3,270 3,270 2,540 730 5,000 - - 0
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 - - 6,720 6,720 6,720 786,240.00 0
tablet salut
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg 214.00 - - - - 0
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 10 10 - 10 - - 0
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - 0
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 - - - - 0
208 tablet 84.00 500 500 500 3,000 - - 0
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 2,000 2,000 1,580 420 1,000 1,000 1,000 86,000.00 2,000

210 93.00 300 300 - 300 - - 0
211 Vapril 25 mg tablet 193.00 320 300 620 490 130 - - 300
212 box 6,550.00 - - - - 0
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 600 3,000 3,600 2,600 1,000 5,000 1,500 1,500 184,500.00 3,000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 170 300 470 256 214 300 100 100 113,600.00 300
215 Vitamin B12 tablet 50 mcg tablet 52.00 1,414 2,000 2,000 859 1,141 3,000 3,000 3,000 156,000.00 2,000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - 0
Page 328
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
217 Vitamin B6 10 mg tablet 138.00 - - - - 0
218 9,646.00 - - - - 0
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - - 50 - - 0
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - 0
221 Hemafort tablet 834.90 3,600 3,600 7,200 3,600 3,600 3,600 3,600 3,600 3,005,640.00 0

222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 35 40 75 40 35 - - 0
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - 0
224 Kapsul 581.00 - - - - 0
IU
225 Allkohol 70% bottle 28,733.33 - - - - 0
226 Alkohol 70% 1L botol 28,750.00 2 2 2 10 - - 0
227 Arm sling L buah 17,424.00 - - - - 0
228 Arm sling M buah 17,424.00 - - - - 0
229 Arm sling S buah 17,424.00 - - - - 0
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - 0
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 49 49 8 41 - - 0
232 Aximed Syringe 1 cc Dus 103,750.00 - - 500 500 500 51,875,000.00 0
233 Aximed Syringe 3 cc Dus 1,031.25 860 2,000 2,860 1,265 1,595 3,000 1,000 1,000 1,031,250.00 2,000
234 Blood Lancet box 16,022.60 100 100 - 100 - - 0
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - - - 0
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - - 0
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - - - 0
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 60 60 12 48 60 12 12 496,380.00 0
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - - - - 0
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 24 24 - 24 72 72 72 2,616,480.00 0
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 60 60 120 49 71 - - 0
Page 329
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 36 36 - 36 72 72 72 2,616,480.00 0
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - 100 - - 0
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 20 20 20 100 - - 20
250 Catheter Tro-Venocath, Sine 26 G pcs 23,843.00 9 20 29 27 2 50 30 30 715,290.00 20
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - 0
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - 0
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - - 0
255 Dermafix T 10x12cm pcs 6,939.90 20 20 - 20 - - 0
256 Examination Gloves size L box 58,564.00 - - 10 10 10 585,640.00 0
257 Examination Gloves size M box 58,564.00 - - 10 5 5 292,820.00 0
258 Examination Gloves size S box 58,564.00 - - - - 0
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - - 0
260 Folley catheter 2 way no. 16 pcs 8,800.00 - - - - 0
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - 0
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - 0
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - 0
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - 0
267 Hb Sahli set 96,800.00 - - - - 0
268 Hidrogen Peroxide 3% botol 3,864.00 - - 5 5 5 2 2 7,728.00 5
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 5 5 5 - - 0
270 Infuset pcs 6,166.16 - - - - 0
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - 30 30 30 244,952.40 0
274 IV- Cath WP, with wings & port no 26 pcs 10,477.39 - - - - 0
275 Kapas pembalut 250 gr roll 13,733.33 - - - - 0
276 Kapas pembalut 250 gr roll 13,750.00 15 10 25 8 17 20 10 10 137,500.00 10
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 20 20 - 20 50 - - 10
278 Kasa kompres steril 40 x 40 pcs 1,760.00 100 130 230 132 98 100 100 100 176,000.00 100
Page 330
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 100 100 10 90 - - 0
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - 0
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 20 20 - 20 - - 0
282 Lysol 1 liter botol 47,150.00 4 4 8 8 10 - - 2
283 Masker Ear Loop Box 20,202.00 5 1 6 6 50 - - 0
284 Masker Tie on Box 19,869.00 5 3 8 8 50 - - 0
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - 0
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - 0
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - 10 10 10 83,853.00 0
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - 0
289 Onemed Alcohol Swab botol 11,000.00 - - - - 0
290 Onemed Blood Lancet box 16,022.60 - - - - 0
291 Onesept 500 ml botol 30,360.00 - - - - 0
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 12 12 2 10 - - 0
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - 0
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - - - - 0
295 Safeglove Examination Gloves L box 39,182.00 - - - - 0
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 50 50 20 30 - - 50
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - 12 12 12 302,220.00 0
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - - 0
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - 72 - - 0
300 Stera Infuset anak pcs 3,850.00 - - - - 0
301 Surgical Mask Earloop box 18,150.00 12 12 9 3 - - 10
302 Surgical Mask Tie On box 18,150.00 - - - - 0
303 Swab 2 ply dus 14,040.84 - - - - 0
304 Syringe 10 cc dus 167,266.70 - - - - 0
305 Syringe 1cc pcs 1,045.80 138 138 - 138 100 - - 0
306 Syringe 1cc dus 106,523.56 - - - - 0
307 Syringe 3cc dus 107,421.38 - - - - 0
308 Syringe 5cc dus 119,090.61 2 2 - 2 - - 2
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - 0
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - 0
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - 0
Page 331
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
312 Tp. Disposable Syringe 5 cc pcs 892.78 - - - - 0
313 pcs 7,072.50 25 25 - 25 10 10 10 70,725.00 25
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - 0
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - 0
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - 0
318 Urine bag steril (t-valve) pcs 3,300.00 10 10 - 10 - - 10
319 HIV Device Box 707,143.00 28 28 28 - - 28

BELANJA OBAT DAN BMHP PENGOBATAN
- - 0
GRATIS
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 38 38 - 38 - - 0
VAKSIN - - 0
321 BCG +Pelarut BCG Vial 61,996.00 - - - - 0
322 Campak + Pelarut Campak Vial 28,204.00 - - - - 0
323 DPT-HB-Hib Vial 78,991.00 - - - - 0
324 DT Vial 17,996.00 - - - - 0
325 Hepatits B Buah 23,991.00 - - - - 0
326 IPV Vial 139,760.00 - - - - 0
327 IPV Vial 144,540.00 - - - - 0
328 MR Vial 141,648.00 - - - - 0
329 Polio+ Dropper Polio Vial 19,954.00 - - - - 0
330 Td Vial 16,995.00 - - - - 0
ANTI RABIES - - 0
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 2 2 - 2 - - 0
332 Albendazol 400 mg tablet 258.74 23,425 23,425 23,425 - - 0
OBAT GIZI - - 0
333 Tablet Tambah Darah (Rematri) tablet 372.00 28,758 28,758 9,185 19,573 - - 0
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - 0
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - 0
OBAT MALARIA - - 0
Page 332
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
336 Blood Slide Kotak 18,509.00 - - - - 0
337 DHP Frimal tablet 3,498.00 - - - - 0
338 Kelambu GF Buah 61,077.00 - - - - 0
339 Primaquin 15 mg tablet 235.00 - - - - 0
OBAT KIA IBU - - 0
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 10 10 20 10 10 - - 0
341 Ca. Glukonas Injeksi ampul 10,351.00 3 3 6 3 3 - - 0
342 Euthyrox 50 mcg tablet 735.00 - - - - 0
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 20 20 40 20 20 - - 0
344 Methylergometrin Injeksi ampul 3,102.00 20 20 40 32 8 50 25 25 77,550.00 0
345 MgSO4 20 % fls 3,328.00 12 12 24 12 12 - - 0
346 MgSO4 40 % fls 3,796.00 12 12 24 12 12 - - 0
OBAT KIA ANAK - - 0
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - 0
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - 0
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 35 50 85 73 12 - - 0
OBAT TB PARU - - 0
350 Box Slide Kotak 41,342.00 - - - - 0
351 Kaca Slide Kotak 30,000.00 - - - - 0
352 Kaca Slide Kotak 20,747.00 6 6 - 6 - - 6
353 OAT Kategori Anak Paket 232,518.00 - - - - 0
354 OAT Kategori I Paket 377,900.00 14 14 12 2 - - 0
355 OAT Kategori II Paket 1,259,990.00 - - - - 0
356 Pot Sputum Pot 2,500.00 1,800 1,800 - 1,800 - - 1,800
357 Reagen Ziehl Neelsen Kit 276,000.00 30 25 55 - 55 - - 25
358 Sputum Pot Buah 2,950.00 360 360 60 300 - - 0
359 Tuberkulin Vial 625,900.00 - - - - 0
KUSTA - - 0
360 MDT PB Dewasa Blister 12,569.00 - - - - 0
361 Paket ADRK II Paket 422,980.00 - - 1 - - 0
IMUNISASI - - 0
362 ADS 0,05 ml Buah 1,518.00 - - - - 0
Page 333
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - 0
364 ADS 0,5 ml Buah 1,127.00 - - - - 0
365 ADS 0,5 ml Buah 1,090.00 - - - - 0
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - 0
367 ADS 0,5 ml SKIFA buah 1,240.00 3,500 3,500 - 3,500 - - 0
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 5 5 - 5 - - 5
369 ADS 5 ml buah 1,705.00 - - - - 0
370 ADS 5 ml Buah 1,705.00 - - - - 0
371 ADS 5 ml Buah 1,439.00 - - - - 0
372 ADS 5 ml Buah 1,500.00 - - - - 0
373 RCW Unit 2,266,454.00 - - - - 0
374 Safety Box pcs 16,608.00 150 150 25 125 - - 0
375 Safety Box 2,5 ml Buah 12,500.00 - - - - 0
376 Safety Box 5 ml Buah 20,394.00 200 200 - 200 - - 200
377 Vaccine Carrier buah 1,870,000.00 - - - - 0
378 Oseltamivir kapsul 12,969.00 - - - - 0
OBAT DIARE - - 0
379 Garam Oralit Sachet 257.00 - - - - 0
380 Garam Oralit Sachet 253.00 169 169 91 78 - - 0
381 Zink Tablet tablet 551.00 1,297 1,297 820 477 1,000 1,000 1,000 551,000.00 0
OBAT HIV/AIDS - - 0
382 Rapid 1 : SD HIV test 11,975.00 200 200 - 200 - - 0
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - 0
384 Rapid Sifilis Ab test 20,400.00 100 100 - 100 - - 0
385 RPR Sifilis test 4,250.00 - - - - 0
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - 0
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - 0
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - - 0
389 Rapid 2 HIV (Focus) test 13,615.00 100 100 - 100 - - 100
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - 0
Page 334
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
391 Rapid 3 Diagnostar test 13,771.00 - - - - 0
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - 0
393 Rapid Sifilis Trepocheck test 9,697.00 225 225 - 225 - - 225
394 RPR Sifilis test 4,250.00 - - - - 0
OBAT KATARAK - - 0
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - - 0
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - - 0
OBAT PROGRAM - - 0
397 L- Zinc botol 31,350.00 33 33 17 16 - - 0
398 Lagesil Suspensi botol 40,755.00 20 20 - 20 - - 0
REAGENTIA - - 0
399 Objek Gelas Kotak 50,000.00 - - - - 0
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - 0
REAGENSIA - - 0
401 Larutan Alkohol 96% botol 242,000.00 - - - - 0
402 Larutan Metanol botol 665,500.00 - - - - 0
403 Reagen Benedict botol 484,000.00 - - - - 0
404 Reagen Natrium Sitrat botol 514,250.00 - - - - 0
405 Reagen Receker botol 2,238,500.00 - - - - 0
406 Reagensia Asam Asetat botol 544,500.00 - - - - 0
407 Slide test widal Unit 302,500.00 - - - - 0
BELANJA STICK NARKOBA - - 0
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - 0
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 154 154 - 154 - - 0
PENINGKATAN KESEHATAN MASYARAKAT - - 0
410 Stick Pemeriksaan Asam Urat Box 231,200.00 1 1 1 - - 0
411 Stick Pemeriksaan Gula Darah Box 231,200.00 8 8 5 3 - - 0
412 DHP Frimal TAblet 2,134.00 9 9 - 9 - -

413 Lysol 1 liter Botol 82,150.00 8 8 - 8 40 40 40 3,286,000.00
414 Povidone Botol 5,186.50 48 48 - 48 - -
415 Lorazepam 1 mg tablet 715.00 300 300 250 50 - -
416 Resperidon tablet 2 mg tablet 287.00 500 500 - 500 - -
Page 335
JUMLAH PEMBERIAN
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
417 Alkohol 70% 1L botol 230,000.00 10 10 5 5 10 10 10 2,300,000.00
418 Hand Sanitizer test 215,000.00 5 5 - 5 10 10 10 2,150,000.00
419 Rapid Test SD Bioline HBsAg test 8,050.00 75 75 25 50 - -
420 Focus Diagnostic Syphilis test 13,900.00 100 100 - 100 - -
421 Focus New HIV test 13,235.00 50 50 - 50 - -
422 Obat Anti Tuberculosis FDC Kategori 1 Paket 408,810.00 10 10 - 10 - -
423 Clobazam 10mg tablet 776.00 300 300 - 300 - -
424 Clozapim 25 mg tablet 1,121.00 300 300 - 300 - -
425 Kertas saring lembar 90 90 - 90 - -
426 Blood Lancet pcs 50 50 - 50 - -
427 plastik pcs 50 50 50 - -
428 Cover All set 30 30 30 - -
429 Masker buah 325 325 225 100 - -
430 Sarung Tangan pcs 300 300 300 - -
431 Sarung Tangan Rubber pcs 5 5 - 5 - -
432 Baju Jas Hujan pcs 20,000.00 1 1 - 1 - -
433 Baju Sauna pcs 272,000.00 1 1 - 1 - -
434 Masker N95 pcs 191,500.00 25 25 18 7 - -
435 Kaca Mata Google pcs 5 5 2 3 - -
436 Helm APD pcs 3 3 - 3 - -
437 Helm APD buah 500,000.00 2 2 1 1 - -
438 Paket Cover All and Face Slied pcs 897,000.00 5 5 5 - -
APD set(Helm,Kaca mat google,sarung tangan,Baju
439 set 2,500,000.00 5 5 5 - -
Hazmat)
Masker box 450,000.00 20 20 20 9,000,000.00
TOTAL 117,657,206.40

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt H. Syamsul Bahri, SKM Rianna, Amk
Page 336
DINKES
PUSKESMAS : AEK KOTA BATU LAPORAN TRIWULAN : I (II) III IV GFK 4/GFK/3/2020 28-Jul-20
KECAMATAN : NA IX-X PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 800 - 800 700 100 5,000 - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - - - - - - - -
3 Alopurinol tablet 100 mg tablet 97.00 1,120 3,000 4,120 2,620 1,500 3,000 2000 2,000 194,000
5 Ambroxol 15 mg/5 ml botol 6,600.00 182 200 382 92 290 300 200 200 1,320,000
6 Ambroxol tab 30 mg tablet 330.00 1,880 4,000 5,880 1,880 4,000 4,000 2000 2,000 660,000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 90 90 180 40 140 - - -
8 Aminofilin tablet 200 mg tablet 92.00 470 - 470 70 400 - - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 960 5,400 6,360 2,460 3,900 - - -
11 tablet 78.00 - - - -
12 Kaplet 94.00 - 300 300 300 28,200
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 - - - -
17 kaptab 261.00 5,000 5,000 4,500 500 5,000 5000 5,000 1,305,000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - -
19 Antasida Tablet box 5,594.00 - - -
20 Antasida Tablet tablet 200.00 - - - - 3,300 3,300 10,000 - -
21 Antasida Tab Tablet 355.00 10,000 10,000 5,000 5000 5,000 1,775,000
Page 337
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
22 tablet 60.00 - - -
23 botol 2,189.00 5 250 255 105 150 500 100 100 218,900

+ Polimiksin 10.000
3,071.00
IU/g 25 25 25 - - - -

25 pot 4,540.00 25 25 - 25 - - -
Asam Salisilat 3%

26 3,325.00 30 30 - 30 - - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 30 - 30 - 30 - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 450 500 950 450 500 800 500 500 122,500
31 Asiklovir Tablet 200 mg Tablet 560.18 500 - 500 500 - - - -
33 Bedak salisil serbuk 2% dus 1,040.00 8 20 28 26 20 25 - -
34 Bedak Salisil Kotak 8,000.00 25 25 25 200,000
35 Betametason krim 0,5 mg/g tube 3,388.00 - 50 50 25 25 - - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 53 - 53 53 - 50 50 50 67,000
37 Ampul 130,999.00 - - 10 - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - 5 5 5 2,561,020
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 - - - - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 74 - - 2 72 - - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 48 48 48 - 72 72 72 225,936
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 700 - 700 1,100 300 5,000 - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 7 - 7 7 - 50 - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - -
tablet
46 Cetirizin Hydrochloride salut 94.00 - - - - - - - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 2,000 2,000 4,000 - 5,000 1000 1,000 101,000
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 - - 200 200 200 594,600
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - -
Page 338
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
50 salut 165.00 190 500 690 90 600 - - -
selaput
51 kapsul 770.00 1,240 1,000 2,240 640 1,600 1,000 500 500 385,000
52 Codeine 10 mg tablet 600.00 480 - 480 80 400 - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 176 200 376 76 300 100 50 50 109,500
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 1,090 1,500 2,590 1,190 1,400 3,000 1000 1,000 133,000
56 tablet 47.00 - - - 5,000 - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 220 240 460 270 190 200 100 100 115,200
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 100 6,000 6,100 6,100 - 6,000 6000 6,000 198,000
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - -
61 Dekstrofen Syrup Botol 11,550.00 200 150 350 150 200 200 50 50 577,500
62 Diazepam 2 mg Tablet 86.00 200 - 200 100 100 100 - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 10 10 20 - 20 10 10 10 18,220
65 Diclofenac Sodium 25 mg Tablet 141.00 2,000 2,000 600 1,400 2,000 - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - - 5,600 5600 5,600 761,600
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 510 - 510 510 - 250 - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - - 300 300
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - -
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - -
71 Digoksin 0,25 mg Tablet 104.00 - - - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 400 - 400 400 - - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 117 100 217 152 65 200 150 150 417,150
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 1,950 - 1,950 1,950 - 4,000 - -
75 Domperidon tablet 10 mg tablet 86.00 4,000 4,000 1,000 3,000 1,500 1500 1,500 129,000
Page 339
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 5 - 5 - 5 - - -
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 6 - 6 - 6 - - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 500 700 1,200 400 800 500 - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 18 10 28 13 15 50 - -
84 Fenobarbital tablet 30 mg tablet 165.00 1,450 - 1,450 - 1,450 - - -
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 48 48 - 48 50 - -
87 tablet 747.00 800 - 800 400 400 1,000 - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 1,000 1,000 - 1,000 300 300 300 239,100
89 ampul 3,867.00 180 180 60 120 150 30 30 116,010
mg/ml
91 Furosemid Inj 10 mg/ml ampul 1,333.00 25 25 - 25 20 - -
92 Furosemide tablet 40 mg tablet 77.00 1,200 2,000 3,200 2,400 800 2,000 - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 120 120 72 48 150 24 24 67,440
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 - - 24 24 24 106,848
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 3,600 5,000 8,600 1,400 7,200 6,000 1500 1,500 187,500
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 40 - 40 40 - 60 20 20 147,260
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 400 500 900 500 400 500 500 500 122,500

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 10 - 10 - 10 - - -
101 Haloperidol 0,5 mg Tablet 55.00 790 - 790 390 400 300 - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - 100 100 100 16,300
103 Hidrokortison krim 2,5 % tube 2,640.00 104 100 204 - 204 50 48 48 126,720
Page 340
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
105 Hustab Syrup botol 11,550.00 50 200 250 150 100 300 150 150 1,732,500
106 Hustab P Tablet 8 mg Tablet 256.67 2,650 3,000 5,650 2,650 3,000 3,000 - -
107 Hustab Tablet tablet 437.00 - - 3,000 3000 3,000 1,311,000
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - - -
selaput
tablet
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 3,070 - 3,070 - 3,070 7,000 300
selaput
111 Ibuprofen 400 mg Tablet 800.00 - - 300 300 300 240,000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 - 100 100 100 - 300 100 100 260,100
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 320 - 320 - 320 3,000 - -
116 tablet 63.00 3,000 3,000 2,000 1,000 3,000 2000 2,000 126,000
118 Kaptopril 12,5 mg tablet 68.00 2,000 2,000 - 2,000 2,000 2000 2,000 136,000
119 Ketokenazol tablet 200 mg tablet 278.00 - - - - - -
120 Ketokonazol tablet 200 mg tablet 297.00 500 500 50 450 2,000 - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 950 - 950 150 800 3,000 - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 1,500 1,500 1,500 - 700 700 700 462,000
124 Kloramfenikol salep mata 1 % Tube 2,007.00 126 - 126 126 - - - -
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 154 200 354 104 250 100 - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - 100 100 100 516,800
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 - - - - - - - -
129 Klorfeniramin maleat tablet 25.00 7,000 7,000 5,600 1,400 7,000 7000 7,000 175,000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 3,430 - 3,430 2,530 900 2,000 1360 1,360 412,080
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 - - - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 300 1,200 1,500 600 900 5,000 500 500 130,000
134 Meloksikam 7,5 mg tablet 795.68 1,500 - 1,500 1,500 - 3,000 - -
Page 341
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
135 Meloxicam tab15 mg tablet 1,438.80 1,000 1,000 1,000 - 500 500 500 719,400
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 250 1,000 1,250 1,250 - 3,000 300 300 31,800
138 tablet 137.00 560 5,000 5,560 4,260 1,300 6,000 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - - 2,000 2000 2,000 292,000

tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 300 - 300 100 200 100 100 100 22,200
selaput
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 810 1,000 1,810 910 900 1,000 1000 1,000 80,000
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 50 100 150 15 135 100 50 50 197,500
146 Metronidazole tablet 500 mg tablet 264.00 900 2,000 2,900 2,700 200 5,000 2000 2,000 528,000
147 MgSO4 20 % botol 13,500.00 10 - 10 - 10 6 - -
148 MgSO4 40 % botol 13,500.00 12 - 12 - 12 6 - -
150 NaCl 0,9 % 500 ml botol 6,840.00 89 - 89 89 - 80 80 80 547,200
151 tablet 132.00 40 - 40 40 - 3,000 - -
25 mg
152 tablet 127.00 800 5,600 6,400 2,350 4,050 3,000 - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 2,100 2,000 4,100 1,000 3,100 2,000 600 600 66,000
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 360 - 360 160 200 1,000 - -
155 Nystatin tablet 500.000 IU Tablet 886.00 500 500 500 - 300 300 300 265,800
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - 30 - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - 500 - -
161 Omeprazol Tab Tablet 650.00 - 1,400 1,400 500 900 4,000 400 400 260,000
Page 342
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
164 Paracetamol kaplet 500 mg kaplet 165.00 750 10,000 10,750 1,650 9,100 10,400 10400 10,400 1,716,000
165 bottle 6,981.00 - - 100 - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 69 69 10 59 500 - -
167 Pehacain Injeksi ampul 3,113.06 231 - 231 31 200 300 - -
168 Pehacain Injeksi Ampul 3,113.05 500 500 - 500 300 300 300 933,915
169 Pehamoksil Tablet 500 mg Tablet 759.00 530 - 530 530 - 5,000 - -
170 Pehastan 500 mg tablet 445.50 2,020 7,000 9,020 8,420 600 7,000 3600 3,600 1,603,800
171 Pehavral tablet 935.00 1,000 1,000 - 1,000 2,000 2000 2,000 1,870,000
172 Perak sulfadiazin krim 1% tube 20,700.00 11 25 36 5 31 30 - -
173 Peridol Syrup 60 ml botol 19,800.00 120 120 120 - 200 - -
174 botol 124,355.00 2 - 2 - 2 2 2 2 248,710
0,2 %
175 Phaproxin 500 mg tablet 880.00 550 3,000 3,550 1,650 1,900 3,600 3600 3,600 3,168,000
176 tablet 302.00 72 - 72 72 - 50 - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 - - 100 100 100 32,200
180 Tablet 124.00 750 - 750 500 250 3,000 - -
(HCl)
181 tablet 129.00 800 500 800 800 - 3,000 3000 3,000 387,000
(HCl)
182 Prednison tablet 5 mg tablet 76.00 2,000 2,000 1,200 800 2,000 2000 2,000 152,000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 2,050 - 2,050 2,050 - - - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 2,270 2,000 4,270 770 3,500 2,000 300 300 42,600
185 Pyridol Syrup 60 ml botol 18,150.00 14 - 14 14 - 300 - -
186 Ranitidin 150 mg Tablet tablet 660.00 160 3,000 3,160 3,160 - 7,000 2200 2,200 1,452,000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 160 - 160 160 - 300 - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 200 200 200 - 200 - -
189 Retinol/ Vit A 100.000 UI capsule 304.00 200 200 - 200 200 200 200 60,799
190 Retinol/ Vit A 200.000 UI capsule 543.99 - - - - -
191 Ringer Laktat 500 ml botol 7,630.00 50 300 350 350 - 500 300 300 2,289,000
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 1,000 - 1,000 500 500 2,000 2000 2,000 126,000
Page 343
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,500 1,000 2,500 2,000 500 1,000 1000 1,000 80,000
198 pot 2,654.00 24 24 48 - 48 24 24 24 63,696
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 1,000 1,000 1,000 - 1,000 700 700 847,000
200 Seftriakson serb inj 1.000 mg vial 4,998.00 10 10 10 - 200 50 50 249,900
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 74 - 74 54 20 200 - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 3,840 - 3,840 3,840 - 3,000 - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 1,020 1,020 1,020 - 5,040 5040 5,040 589,680
tablet
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg salut 214.00 2,000 - 2,000 - 2,000 - - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 19 20 39 20 19 - - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 40 - 40 40 - - - -
208 tablet 84.00 1,620 - 1,620 1,620 - 2,000 - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 2,000 2,000 - 2,000 2,000 2000 2,000 172,000
tablet
210 salut 93.00 100 - 100 - 100 - - -
selaput
211 Vapril 25 mg tablet 193.00 2,000 2,000 4,000 800 3,200 2,000 2000 2,000 386,000
212 box 6,550.00 - - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 1,620 3,500 5,120 3,220 1,900 5,000 2000 2,000 246,000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 200 200 200 - 500 300 300 340,800
215 Vitamin B12 tablet 50 mcg tablet 52.00 750 5,000 5,750 3,950 1,800 5,000 5000 5,000 260,000
218 9,646.00 - - - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 33 - 33 33 - 60 - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 98,500 - 98,500 98,500 - 28,000 28000 28,000 10,416,000
221 Hemafort tablet 834.90 250 1,500 1,750 1,070 700 3,600 3600 3,600 3,005,640
Page 344
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 - - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - -
224 Kapsul 581.00 - - - - -
IU
225 Allkohol 70% bottle 28,733.33 - - - -
226 Alkohol 70% 1L botol 28,750.00 - - 10 - -
227 Arm sling L buah 17,424.00 3 3 6 - 10 2 2 34,848
228 Arm sling M buah 17,424.00 3 3 6 - 15 1 1 17,424
229 Arm sling S buah 17,424.00 3 3 6 - 10 1 1 17,424
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - 20 - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 - 4 4 4 - 20 - -
232 Aximed Syringe 1 cc Dus 103,750.00 2 2 1 1 5 5 5 518,750
233 Aximed Syringe 3 cc Dus 103,125.00 - 20 20 3 17 15 15 15 1,546,875
234 Blood Lancet box 16,022.60 - - - - - -
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 60 - 60 60 - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 36 - 36 36 - - -
237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 - - - - -
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - - - -
239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 60 - 60 60 - - -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 36 24 60 - 24 12 12 496,380
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 36 24 60 - 60 24 12 12 496,380
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - - - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - 200 - -
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - - 400 - -
Page 345
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 50 50 400 39 39 492,609
250 Catheter Tro-Venocath, Sine 26 G pcs 23,843.00 50 50 100 27 27 643,761
255 Dermafix T 10x12cm pcs 6,939.90 70 - 70 - - -
256 Examination Gloves size L box 58,564.00 5 5 10 5 5 292,820
257 Examination Gloves size M box 58,564.00 5 5 10 5 5 292,820
258 Examination Gloves size S box 58,564.00 10 10 10 5 5 292,820
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 5 5 5 5 5 36,270
267 Hb Sahli set 96,800.00 - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - 20 - -
270 Infuset pcs 6,166.16 - - - -
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 50 50 50 50 50 408,254
272 IV- Cath WP, with wings & port no 22 pcs 8,088.85 100 100 50 50 50 404,443
275 Kapas pembalut 250 gr roll 13,733.33 - - - - -
276 Kapas pembalut 250 gr roll 13,750.00 10 10 10 10 10 137,500
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 10 10 50 - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 - - 100 100 100 176,000
Page 346
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 50 50 50 50 50 82,500
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - - - -
282 Lysol 1 liter botol 47,150.00 7 7 20 - -
283 Masker Ear Loop Box 20,202.00 - - - - -
284 Masker Tie on Box 19,869.00 5 - 5 100 - -
289 Onemed Alcohol Swab botol 11,000.00 - - - -
290 Onemed Blood Lancet box 16,022.60 - - - -
291 Onesept 500 ml botol 30,360.00 21 - 21 - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 24 - 24 - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 24 24 12 12 12 302,220
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 48 - 48 24 24 24 501,600
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 36 24 60 24 - -
300 Stera Infuset anak pcs 3,850.00 - - - - -
302 Surgical Mask Tie On box 18,150.00 30 30 20 - -
303 Swab 2 ply dus 14,040.84 - - - -
304 Syringe 10 cc dus 167,266.70 - - - -
305 Syringe 1cc pcs 1,045.80 - - 200 - -
306 Syringe 1cc dus 106,523.56 - - - -
307 Syringe 3cc dus 107,421.38 - - - -
308 Syringe 5cc dus 119,090.61 - - - -
Page 347
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

313 pcs 7,072.50 - - - -
Airvent, Luer Lock
318 Urine bag steril (t-valve) pcs 3,300.00 8 - 8 - -
PEMERIKSAAN HIV
319 HIV Device Box 707,143.00 24 24 24 24 24 16,971,432
SUMBER DANA APBD I
VAKSIN
323 DPT-HB-Hib Vial 78,991.00 - - - -
324 DT Vial 17,996.00 - - - -
325 Hepatits B Buah 23,991.00 - - - -
326 IPV Vial 139,760.00 - - - -
327 IPV Vial 144,540.00 - - - -
328 MR Vial 141,648.00 - - - -
330 Td Vial 16,995.00 - - - -
ANTI RABIES
OBAT FILARIASIS
Page 348
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT GIZI
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - -
OBAT MALARIA
336 Blood Slide Kotak 18,509.00 - - 6 6 6 111,054
337 DHP Frimal tablet 3,498.00 - - - -
338 Kelambu GF Buah 61,077.00 - - - -
339 Primaquin 15 mg tablet 235.00 - - - -
OBAT KIA IBU
341 Ca. Glukonas Injeksi ampul 10,351.00 - - 10 9 9 93,159
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - - 20 15 15 55,275
345 MgSO4 20 % fls 3,328.00 - - - -
346 MgSO4 40 % fls 3,796.00 - - 20 - -
OBAT KIA ANAK
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - - 50 50 50 130,000
OBAT TB PARU
350 Box Slide Kotak 41,342.00 - - - -
351 Kaca Slide Kotak 30,000.00 - - - -
352 Kaca Slide Kotak 20,747.00 6 6 - -
353 OAT Kategori Anak Paket 232,518.00 - - 15 - -
354 OAT Kategori I Paket 377,900.00 - - 50 - -
355 OAT Kategori II Paket 1,259,990.00 - - 3 - -
356 Pot Sputum Pot 2,500.00 1,000 1,000 - 1,000 1,600 1600 1,600 4,000,000
Page 349
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
357 Reagen Ziehl Neelsen Kit 276,000.00 - - 20 20 20 5,520,000
358 Sputum Pot Buah 2,950.00 - - - -
359 Tuberkulin Vial 625,900.00 - - - -
KUSTA
360 MDT PB Dewasa Blister 12,569.00 - - - -
361 Paket ADRK II Paket 422,980.00 - - - -
IMUNISASI
362 ADS 0,05 ml Buah 1,518.00 - - 500 - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - -
364 ADS 0,5 ml Buah 1,127.00 - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - 1,000 - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - -
369 ADS 5 ml buah 1,705.00 - - - -
370 ADS 5 ml Buah 1,705.00 - - - -
371 ADS 5 ml Buah 1,439.00 - - - -
372 ADS 5 ml Buah 1,500.00 - - - -
373 RCW Unit 2,266,454.00 - - - -
374 Safety Box pcs 16,608.00 - - - -
375 Safety Box 2,5 ml Buah 12,500.00 - - - -
376 Safety Box 5 ml Buah 20,394.00 - - - -
OBAT FLU BURUNG
OBAT DIARE
381 Zink Tablet tablet 551.00 - - - -
Page 350
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT HIV/AIDS
382 Rapid 1 : SD HIV test 11,975.00 - 200 200 - - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - 125 125 - - -
384 Rapid Sifilis Ab test 20,400.00 - - - 11 - - - -
385 RPR Sifilis test 4,250.00 400 400 - -
OBAT HEPATITIS
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - -
Reagensia/ Alat
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - 250 250 250 2,993,750
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - -
393 Rapid Sifilis Trepocheck test 9,697.00 225 225 50 50 50 484,850
394 RPR Sifilis test 4,250.00 - - - - -
SUMBER DANA APBD II
OBAT KATARAK
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - 5 - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - 10 - -
OBAT PROGRAM -
397 L- Zinc botol 31,350.00 - - - -
398 Lagesil Suspensi botol 40,755.00 - - 200 - -
REAGENTIA -
REAGENSIA
401 Larutan Alkohol 96% botol 242,000.00 - - 10 - -
Page 351
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - 20 - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - 20 - -
Alkohol 70% 1L Botol 230,000.00 10 10 - 10 10 10 10 2,300,000
Lysol 1 liter Botol 82.150,00 20 20 - 20 60 60 60 #VALUE!
DHP Frimal Tablet 2134,00 9 9 9 - 9 9 9 #VALUE!
Fokus Diagnostic syphilis test 13,900.00 100 100 100 100 1,390,000
One Med Povidone Iodine 30 ml botol 3,680.00 125 30 30 50 184,000
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 2,000 2000 2,000 220,000
TOTAL #VALUE!
Diketahui: Diketahui: Yang Menyerahkan Diketahui : Aek Kota Batu, juli 2020
Kepala Dinas Kesehatan Kabid. Sumber Daya Kesehatan Kasie Farmasi Kepala Puskesmas Pengelola Obat
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt dr.ZULHAM ALIWARDANA R RUMONDANG DALIMUNTHE, AM.Keb
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 NIP. 19820210 201704 1 001 NIP.19900605 201410 2 002
Page 352
-
-
3,000
-
200
4,000
90
-
-
-
5,400
-
-
200
-
5,000
-
-
-
10,000
Page 353
-
250
25
25
30
-
-
-
500
-
-
20
-
50
-
-
48
-
-
-
-
2,000
-
-
Page 354
500
1,000
-
-
200
1,500
240
-
6,000
-
150
-
-
10
2,000
-
-
120
-
-
-
-
100
-
4,000
Page 355
-
-
-
700
-
10
-
-
-
48
1,000
180
-
25
2,000
-
120
5,000
500
-
-
-
-
100
-
Page 356
200
3,000
-
7,900
-
-
100
-
3,000
-
2,000
-
500
-
1,500
-
-
200
-
-
-
7,000
-
-
-
1,200
-
Page 357
1,000
-
1,000
5,000
-
-
-
-
-
1,000
100
2,000
-
-
120
-
5,600
2,000
-
500
-
-
-
-
-
1,400
-
-
Page 358
10,000
69
-
500
-
7,000
1,000
25
120
3,000
-
-
-
500
2,000
-
2,000
-
3,000
-
200
200
-
300
-
-
-
Page 359
1,000
-
-
24
1,000
10
-
1,020
20
-
-
2,000
2,000
3,500
200
5,000
-
-
-
-
-
1,500
Page 360
-
200
-
-
3
3
3
-
4
2
20
-
-
-
-
-
-
-
24
-
-
24
-
-
-
-
Page 361
50
50
-
-
-
-
-
5
5
10
-
-
5
5
5
-
-
-
-
-
-
-
50
100
-
-
-
10
10
-
Page 362
50
-
-
7
-
-
-
-
-
-
-
-
-
-
-
-
-
-
24
-
24
-
-
30
-
-
-
-
-
-
Page 363
-
-
-
-
-
-
-
-
-
-
24
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 364
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
100
-
-
-
-
-
-
-
-
-
6
-
-
-
1,000
Page 365
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
175
-
-
-
-
-
-
-
-
-
Page 366
-
200
125
-
400
-
-
-
-
-
-
-
-
-
225
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 367
-
-
-
-
-
-
-
-
-
-
Page 368
DINKES
PUSKESMAS : BANDAR DURIAN LAPORAN TRIWULAN : I (II) III IV GFK 3/GFK/3/2020 24-Jul-20
KECAMATAN : AEK NATAS PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
HARGA STOK PENERI PERSEDI PEMAK SISA STOK PERMIN
NO NAMA OBAT SATUAN APBD TOTAL TOTAL
SATUAN (Rp) AWAL MAAN AAN AIAN STOK OPT TAAN DAK APBD II KET
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
1 Acetyl cysteine/ N-Asetil sistein tablet/kaplet/kapsul 200 mg capsule 357.00 100 100 100 - 120 1,500 - - 0
2 Acyclovir 200 mg Tablet 1,050.00 - - - - 0
3 Alopurinol tablet 100 mg tablet 97.00 1,000 4,000 5,000 3,500 1,500 4,200 6,000 4500 4,500 436,500 4000
4 Alopurinol tablet 100 mg tablet 104.00 - - - - 0
5 Ambroxol 15 mg/5 ml botol 6,600.00 200 200 140 60 168 300 250 250 1,650,000 200
6 Ambroxol tab 30 mg tablet 330.00 3,000 3,000 2,000 1,000 2,400 4,000 3000 3,000 990,000 3000
7 Aminofilin inj 24 mg/ml ampul 2,998.00 24 24 24 - - - 0
8 Aminofilin tablet 200 mg tablet 92.00 600 200 800 800 - - 200
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 200 200 200 - - 0
10 Amlodipine Besilat tablet 5 mg tablet 73.00 400 400 400 - 480 600 - - 0
Amlodipin/Amlodipine/Amlodipine Besylate/Amlodipine Besilate
11
tablet 78.00 900 900 600 300 720 900 900 900 70,200 900
Amlodipin/Amlodipine/Amlodipine Besilate tablet/kapsul/kaplet 10
12
mg
Kaplet 94.00 540 540 200 340 240 300 300 300 28,200 0
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - 0
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - - - 0
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 52 100 152 120 32 144 200 150 150 990,000 100
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 50 180 230 200 30 240 350 240 240 880,800 180
17
kaptab 261.00 6,000 6,000 6,000 - 7,200 10,000 6000 6,000 1,566,000 5000
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - 0
19 Antasida Tablet box 5,594.00 - - - - 0
20 Antasida Tablet tablet 200.00 5,000 6,000 11,000 7,500 3,500 9,000 10,000 - - 6000
21 Antasida Tab Tablet 355.00 - - 6,500 6500 6,500 2,307,500 0
Antasida tab kunyah, kombinasi: Aluminium Hidroksida 200 mg +
22
tablet 60.00 - - - - 0
Antasida suspensi, kombinasi: Aluminium Hidroksida 200 mg +
23
botol 2,189.00 23 200 223 200 23 240 300 200 200 437,800 200
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tube
10.000 IU/g 3,071.00 65 50 115 100 15 120 150 100 100 307,100 50
Antifungi DOEN Salep, Kombinasi: Asam Benzoat 6% + Asam
25
Salisilat 3%
pot 4,540.00 64 64 64 - 76 100 72 72 326,880 0
26 Antihemoroid, Kombinasi sup: bismut subgalat heksaklorofen suppositoria 3,325.00 30 30 30 - - 0

27 Arkine 100 tablet 687.50 - - - - 0
28 Asam Mefenamat 500 mg tablet 242.89 - - - - 0
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 10 10 10 - 12 20 - - 0
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 500 1,000 1,500 1,300 200 1,560 2,000 1500 1,500 367,500 1000
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - 0
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 20 20 20 - - 0
33 Bedak salisil serbuk 2% dus 1,040.00 100 100 90 10 108 150 100 100 104,000 100
34 Bedak Salisil Kotak 8,000.00 - - - - 0
35 Betametason krim 0,5 mg/g tube 3,388.00 40 48 88 75 13 90 150 75 75 254,100 48
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - - - 25
37 Biosat 1,5 Serum antitetanus (A.T.S) inj 1500 IU/amp (i.m) Ampul 130,999.00 9 9 9 - - 0
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - 1 1 1 512,204 0
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg kaptab salut selaput 327.00 - - - - 0
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 230 230 230 - 200 - - 0
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - 72 72 72 225,936 0
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - 1,000 - - 0
43 Cefotaxime sodium 1 gr vial 7,342.50 - - 20 - - 0
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - - 0
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - 0
46 Cetirizin Hydrochloride tablet salut selaput 94.00 - - - - 0
47 Cetirizine tablet 10 mg tablet 101.00 1,500 1,500 1,500 - 1,800 4,000 1000 1,000 101,000 1500
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 84 200 284 250 34 300 300 200 200 594,600 100
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - 0
Chlorpromazine hydrochloride/ Chlorpromazine /Klorpromazin
50
tablet/kaplet salut selaput 100 mg
tablet salut selaput 165.00 - - - - 0
51
kapsul 770.00 - - 600 600 600 462,000 0
52 Codeine 10 mg tablet 600.00 - - - - 0
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 50 50 50 - 60 100 - - 0
Cotrimoxazole/ Cotrimoksazole/ Kotrimoksazol (anak) kombinasi
54 tiap 5 ml suspensi: sulfametoksazol 200 mg + trimetoprim 40 mg botol 2,190.00 23 23 20 3 100 - - 0
(susp 240 mg)
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 mg tablet 133.00 300 1,000 1,300 1,000 300 1,200 2,000 1000 1,000 133,000 1000
(tab/kaptab 480 mg)
56
tab/kaps/kapl/ 50 mg
tablet 47.00 - - - - 0
Deksametason sodium phosphate/Dexamethasone/Deksametason
57
injeksi 5 mg/ml
ampul 1,152.00 190 240 430 400 30 480 500 480 480 552,960 240
58 Dexamethason inj Ampul 4,500.00 - - - - 0
59 Dexametason Tablet 0,5 mg Tablet 33.00 1,500 6,300 7,800 5,000 2,800 6,000 7,000 7000 7,000 231,000 6300
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - 0
61 Dekstrofen Syrup Botol 11,550.00 150 100 250 170 80 204 250 50 50 577,500 100
62 Diazepam 2 mg Tablet 86.00 100 100 100 - - 100
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - 0
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 40 10 50 50 - - 10
65 Diclofenac Sodium 25 mg Tablet 141.00 1,500 1,500 800 700 960 1,500 1000 1,000 141,000 1500
66 Diclofenac Sodium 50 mg Tablet 136.00 - - 5,600 5600 5,600 761,600 0
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 60 60 60 - - - 0
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 210 210 210 - 252 300 270 210
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - 0
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - 0
71 Digoksin 0,25 mg Tablet 104.00 - - - - 0
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 400 400 400 - 480 500 - - 0
73 Domperidon Suspensi 5 mg/5 ml Botol Plastik 2,781.00 146 100 246 170 76 204 250 150 150 417,150 100
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 2,400 2,400 2,400 - 2,880 3,000 - - 0
75 Domperidon tablet 10 mg tablet 86.00 2,000 2,000 1,500 500 1,800 2,000 2000 2,000 172,000 2000
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - - - - 0
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 - - - - 0
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - 0
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 73 73 73 - 87 100 - 0
80 Eritromisin kapl 500 mg kaptab salut selaput 765.00 500 500 300 200 360 600 500 500 382,500 500
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - 0
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 5 5 5 - 6 20 - - 5
83 Eugenol cairan botol 21,091.00 - - - - 0
84 Fenobarbital tablet 30 mg tablet 165.00 - - - - 0
85 Fenobarbital tablet 30 mg tablet 180.00 800 800 800 - - 0
86 Fenol Gliserol Tetes Telinga botol 2,764.00 25 48 73 73 - 87 100 - - 48
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
87 Fitomenadion/Phytomenadion (Vit K) tablet/kaplet salut gula 10 mg tablet 747.00 - - - - 0
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 400 300 700 500 200 600 1,000 300 300 239,100 300
89 Fitomenadion / Phytomenadion (Vitamin k1) injeksi 2 mg/ml ampul 3,867.00 20 60 80 75 5 90 200 90 90 348,030 60
90 Fituno Tab tablet 4,163.10 - - - - 0
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - - 0
92 Furosemide tablet 40 mg tablet 77.00 400 400 800 700 100 840 1,000 - - 400
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - 0
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 24 24 24 - 28 60 24 24 67,440 24
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 24 24 24 - 28 60 24 24 106,848 24
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 1,800 2,000 3,800 3,500 300 4,200 4,500 400 400 50,000 2000
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 13 20 33 30 3 36 40 20 20 147,260 20
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 400 1,500 1,900 1,400 500 1,680 2,000 1500 1,500 367,500 1500
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - 0
100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - 0
101 Haloperidol 0,5 mg Tablet 55.00 - - - - 0
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - 100 100 100 16,300 0
103 Hidrokortison krim 2,5 % tube 2,640.00 20 120 140 100 40 120 200 120 120 316,800 120
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - 0
105 Hustab Syrup botol 11,550.00 146 150 296 220 76 264 300 150 150 1,732,500 150
106 Hustab P Tablet 8 mg Tablet 256.67 200 3,000 3,200 2,800 400 3,360 3,600 3000 3,000 770,010 3000
107 Hustab Tablet tablet 437.00 - - - - 0
108 Ibuprofen tab/kaps/kapl 200 mg tablet salut selaput 108.00 6,000 6,000 4,000 2,000 4,800 5,000 6000
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg tablet salut selaput 105.00 2,500 2,500 2,500 - 0
110 Ibuprofen 200 mg Tablet 550.00 - - 1,500 1500 1,500 825,000 0
111 Ibuprofen 400 mg Tablet 800.00 1,000 1,000 1,000 - 1,200 4,000 700 700 560,000 1000
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 40 150 190 150 40 180 200 - - 150
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - 150 150 150 416,400 0
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 500 500 500 - - 0
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 180 180 180 - 2,000 - - 0
116 Kalsium Laktat/ Calcium lactate (Kalk) tablet/kapsul/kaplet 500 mg tablet 63.00 1,000 3,000 4,000 3,000 1,000 3,600 4,000 2000 2,000 126,000 3000
117 Kanamycin 1 gr inj vial 10,768.00 - - 20 - - 0
118 Kaptopril 12,5 mg tablet 68.00 200 1,500 1,700 1,200 500 1,440 2,000 2000 2,000 136,000 1500
119 Ketokenazol tablet 200 mg tablet 278.00 500 500 500 - 600 2,000 - - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
120 Ketokonazol tablet 200 mg tablet 297.00 1,000 1,000 1,000 - 1,200 1,500 - - 1000
121 Kloramfenicol kapsul 250 mg Capsule 320.00 100 100 100 - - - 0
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 500 500 500 - 600 1,000 600 600 396,000 500
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - 0
124 Kloramfenikol salep mata 1 % Tube 2,007.00 21 21 21 - 25 50 - - 24
125 Kloramfenikol suspensi 125 mg/ 5 ml Botol Plastik 4,843.00 134 250 384 300 84 360 400 - - 250
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - 250 250 250 1,292,000 0
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 1,400 2,000 3,400 1,400 2,000 1,680 2,000 - - 2000
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - 0
129 Klorfeniramin maleat tablet 25.00 1,000 1,000 1,000 - 1,200 3,000 3000 3,000 75,000 1000
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - - 1,200 1200 1,200 363,600 0
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 2,000 2,000 1,700 300 2,040 3,000 - - 2000
132 Lidocaine Injeksi 2 % ampul 1,203.00 - - - - 0
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 1,000 1,000 1,000 - 1,200 3,000 800 800 208,000 1000
134 Meloksikam 7,5 mg tablet 795.68 - - - - 0
135 Meloxicam tab15 mg tablet 1,438.80 3,000 3,000 2,800 200 3,360 5,000 700 700 1,007,160 1000
136 Meloxicam 15 mg Tablet 980.00 - - - - 0
Metformin Hydrochloride/ Metformin tablet/kapsul/kaplet/kaptab
137
tablet salut selaput 106.00 300 750 1,050 500 550 600 1,000 500 500 53,000 750
138 Metilprednisolon/methylprednisolone tab/kaps/kapl 4 mg tablet 137.00 2,300 2,000 4,300 3,500 800 4,200 5,000 - - 2000
139 Metilprednisolon tablet 4 mg tablet 146.00 - - 3,000 3000 3,000 438,000 0
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - 0
141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - 0
142 Metil Ergometrin tablet Salut Selaput 0,125 mg tablet salut selaput 222.00 800 1,000 1,800 1,500 300 1,800 2,000 2000 2,000 444,000 1000
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - 0
144
(hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 mg
tablet 80.00 - - - - 0
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 10 50 60 60 - 72 100 50 50 197,500 50
146 Metronidazole tablet 500 mg tablet 264.00 1,000 1,000 800 200 960 2,000 700 700 184,800 1000
147 MgSO4 20 % botol 13,500.00 - - - - 0
148 MgSO4 40 % botol 13,500.00 - - - - 0
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 12 120 132 90 42 108 150 96 96 344,160 120
150 NaCl 0,9 % 500 ml botol 6,840.00 25 80 105 80 25 96 100 40 40 273,600 80
151 Natrium Diklofenak tablet/kapsul/kaplet salit enterik 25 mg tablet 132.00 1,800 1,800 1,800 - 2,160 2,000 - - 0
152 Natrium Diklofenak tablet/kapsul/kaplet salit enterik 50 mg tablet 127.00 4,250 5,600 9,850 7,000 2,850 8,400 8,000 - - 5600
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 500 1,500 2,000 1,000 1,000 1,200 1,000 1000 1,000 110,000 1500
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 400 400 400 - 480 600 - - 0
155 Nystatin tablet 500.000 IU Tablet 886.00 300 300 300 600 300 300 265,800 300
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - - 0
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - - 0
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - - 0
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - 300 - - 0
161 Omeprazol Tab Tablet 650.00 - - - - 0
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - - - - 0
163 Paracetamol Tab 500 mg tablet 290.00 400 6,000 6,400 5,800 600 6,960 8,000 - - 0
164 Paracetamol kaplet 500 mg kaplet 165.00 - - 6,000 6000 6,000 990,000 6000
Paracetamol/parasetamol drops 100 mg/ml btl @15 ml (60 ml/0,6
165
ml) (G)
bottle 6,981.00 - - 100 - - 0
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml botol 1,184.00 50 50 50 - 100 20 20 23,680 50
167 Pehacain Injeksi ampul 3,113.06 400 500 900 700 200 840 800 - - 0
168 Pehacain Injeksi Ampul 3,113.05 - - 800 800 800 2,490,440 500
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - - 0
170 Pehastan 500 mg tablet 445.50 4,000 4,000 4,000 - 4,800 6,000 4000 4,000 1,782,000 4000
171 Pehavral tablet 935.00 300 3,000 3,300 3,000 300 3,600 4,000 3500 3,500 3,272,500 3000
172 Perak sulfadiazin krim 1% tube 20,700.00 23 30 53 45 8 54 60 10 10 207,000 30
173 Peridol Syrup 60 ml botol 19,800.00 24 24 24 - 100 - - 24
174 Perio Kin Spray Chlorhexidin Gluconat/ Klorheksidin 0,2 % botol 124,355.00 5 5 5 3 3 3 373,065 5
175 Phaproxin 500 mg tablet 880.00 500 500 500 - 600 800 800 800 704,000 500
176 Pirantel pamoat / pyrantel pamoate tab/kaps/kapl 125 mg tablet 302.00 - - - - 0
177 Pirantel pamoat 125 mg tab tablet 322.00 200 200 150 50 180 200 - - 200
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - - - - 0
179 Pirantel Pamoat syrup botol 10,778.00 - - - - 0
180 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 124.00 5,550 5,550 5,550 - - - 0
181 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) tablet 129.00 3,000 3,000 1,000 2,000 1,200 3,000 3000 3,000 387,000 3000
182 Prednison tablet 5 mg tablet 76.00 3,000 3,000 2,500 500 3,000 3,000 3000 3,000 228,000 3000
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 700 700 700 - - - 0
184 Pularex Attapulgit tab 630 mg tablet 142.00 1,000 1,000 800 200 960 1,000 800 800 113,600 1000
185 Pyridol Syrup 60 ml botol 18,150.00 - - - - 0
186 Ranitidin 150 mg Tablet tablet 660.00 1,000 4,000 5,000 4,000 1,000 4,800 6,000 3000 3,000 1,980,000 4000
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - - - 0
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 300 300 300 - 360 400 200 200 231,000 300
191 Ringer Laktat 500 ml botol 7,630.00 145 160 305 290 15 348 350 200 200 1,526,000 160
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 - - - - 0
194 Salbutamol 2 mg tab tablet 67.00 - - - - 0
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 2,000 2,000 1,400 600 1,680 2,000 2000 2,000 160,000 2000
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 500 500 500 - - - 0
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - - - 0
198 Salep 2-4, kombinasi: asam salisilat 2% + belerang endap 4% pot 2,654.00 61 48 109 80 29 96 100 96 96 254,784 48
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 500 500 500 - 600 1,000 700 700 847,000 500
200 Seftriakson serb inj 1.000 mg vial 4,998.00 10 10 10 - 12 20 20 20 99,960 10
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 - - - - 0
202 Simvastatin tab/kapl/salut selaput 10 mg Tablet Salut Selaput 110.00 780 780 780 - 936 1,000 - - 0
203 Simvastatin tablet 10 mg Tablet 117.00 - - 1,680 1680 1,680 196,560 600
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg tablet salut selaput 214.00 960 960 960 - 1,152 1,000 - - 0
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 10 10 2 8 - - 0
206 Stesolid 10 mg/2,5 ml tube 19,193.00 10 10 10 - - 0
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 200 100 300 300 - 360 1,000 - - 100
208 Tiamin (Vitamin B1) Tablet/Kapsul/kaplet 50 mg (HCL/Nitrat) tablet 84.00 300 300 600 600 - 720 800 - - 300
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 1,500 1,500 1,000 500 1,200 1,500 1000 1,000 86,000 1500
210
tablet salut selaput 93.00 200 100 300 300 - - 100
211 Vapril 25 mg tablet 193.00 500 1,500 2,000 1,700 300 2,040 3,000 3000 3,000 579,000 1500
212 Ventolin Rotahaler (Alat Hirup Salbutamol 200 mcg/kapsul) box 6,550.00 - - - - 0
213 Vitamin B Kompleks tablet 123.00 400 3,000 3,400 3,400 - 4,080 5,000 3000 3,000 369,000 3000
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 100 400 500 400 100 480 500 500 500 568,000 400
215 Vitamin B12 tablet 50 mcg tablet 52.00 1,000 5,000 6,000 4,500 1,500 5,400 5,000 5000 5,000 260,000 5000
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - 0
217 Vitamin B6 10 mg tablet 138.00 - - - - 0
218 Wida Bes Asetat Ringer (Asering) (Softbag, Flexy bag, plabot Botol Plastik 9,646.00 - - - - 0
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - - 100 - - 0
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - 0
221 Hemafort tablet 834.90 500 3,000 3,500 3,500 - 4,200 7,200 7200 7,200 6,011,280 3000
222
magnesium chloride anhydrous, potassium chloride, zinc acetate)
sachet 3,116.00 - - - - 0
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - 0

JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
224 Retnol Acetat/ Retinol (Vitamin A) Kaps Lunak 200.000 IU Kapsul 581.00 - - - - 0
225 Allkohol 70% bottle 28,733.33 - - - - 0
226 Alkohol 70% 1L botol 28,750.00 - - 20 - - 0
227 Arm sling L buah 17,424.00 2 2 2 - - 0
228 Arm sling M buah 17,424.00 1 1 1 - - 0
229 Arm sling S buah 17,424.00 1 1 1 - - 0
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - 0
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 31 2 33 25 8 30 50 - - 2
232 Aximed Syringe 1 cc Dus 103,750.00 - - 10 10 10 1,037,500 0
233 Aximed Syringe 3 cc Dus 103,125.00 5 10 15 14 1 16 20 15 15 1,546,875 10
234 Blood Lancet box 16,022.60 3 2 5 5 - 6 12 3 3 48,068 2
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 24 24 24 - 28 60 - - 0
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - 24 24 24 1,023,960 0
240 Catgut chromic 3/0 HR 30 mm Sachet 33,873.38 84 84 84 - 100 100 96 96 3,251,845 36
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 36 36 24 12 28 60 24 24 992,760 0
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - - 0
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 42 36 78 78 - 93 150 96 96 3,488,640 36
249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 20 20 20 - 100 20 20 252,620 20
250 Catheter Tro-Venocath, Sine 26 G pcs 23,843.00 20 20 20 - 100 20 20 476,860 20
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - 0
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - - 0
255 Dermafix T 10x12cm pcs 6,939.90 - - - - 10
256 Examination Gloves size L box 58,564.00 10 10 10 - - - 10
257 Examination Gloves size M box 58,564.00 - - 15 10 10 585,640 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
258 Examination Gloves size S box 58,564.00 - - - - 0
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - 10 10 10 374,400 0
260 Folley catheter 2 way no. 16 pcs 8,800.00 - - - - 0
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 239 239 100 139 100 100 100 725,400 0
264 Gynaecologycal Glove, Large pcs 40,733.00 - - 10 10 10 407,330 0
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - 10 10 10 407,330 0
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - 0
267 Hb Sahli set 96,800.00 - - - - 0
268 Hidrogen Peroxide 3% botol 3,864.00 - - - - 0
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - 0
270 Infuset pcs 6,166.16 200 200 180 20 216 300 55 55 339,139 0
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - 100 50 50 408,254 0
275 Kapas pembalut 250 gr roll 13,733.33 - - 20 - - 0
276 Kapas pembalut 250 gr roll 13,750.00 - - 15 15 15 206,250 0
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 38 38 38 - 300 5 5 41,200 20
278 Kasa kompres steril 40 x 40 pcs 1,760.00 400 400 400 - 300 100 100 176,000 200
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 40 100 140 130 10 200 100 100 165,000 100
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - 0
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - 200 20 20 162,448 0
282 Lysol 1 liter botol 47,150.00 5 20 25 25 - 20 - - 20
283 Masker Ear Loop Box 20,202.00 6 6 6 - 30 - - 0
284 Masker Tie on Box 19,869.00 10 10 10 - 20 - - 10
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - 0
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - 0
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - - 0
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - 0
289 Onemed Alcohol Swab botol 11,000.00 - - 20 20 20 220,000 0
290 Onemed Blood Lancet box 16,022.60 - - - - 0
291 Onesept 500 ml botol 30,360.00 - - - - 0
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 - - - - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - 0
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - - - - 0
295 Safeglove Examination Gloves L box 39,182.00 - - - - 0
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - - - 0
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - 72 72 72 1,813,320 0
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - - 0
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 50 24 74 74 - 120 - - 24
300 Stera Infuset anak pcs 3,850.00 17 17 17 - 100 - - 0
301 Surgical Mask Earloop box 18,150.00 - - 10 5 5 90,750 0
302 Surgical Mask Tie On box 18,150.00 - - 10 10 10 181,500 0
303 Swab 2 ply dus 14,040.84 - - 50 - - 0
304 Syringe 10 cc dus 167,266.70 1 1 1 - - 0
305 Syringe 1cc pcs 1,045.80 800 800 800 - 960 1,000 1000 1,000 1,045,800 0
306 Syringe 1cc dus 106,523.56 - - - - 0
307 Syringe 3cc dus 107,421.38 - - 10 - - 0
308 Syringe 5cc dus 119,090.61 180 180 150 30 4 4 4 476,362 0
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - 0
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - 0
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - 0
312 Tp. Disposable Syringe 5 cc pcs 892.78 - - - - 0
Tp. Infusion Set Pediatric 60 drops/ml with Y Type, Airvent, Luer
313
Lock
pcs 7,072.50 50 50 15 35 50 50 50 353,625 50
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - 0
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - 0
318 Urine bag steril (t-valve) pcs 3,300.00 - - - - 0
319 HIV Device Box 707,143.00 - - - - 0
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS - - 0
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - - - - 0
VAKSIN - - 0
321 BCG +Pelarut BCG Vial 61,996.00 - - - - 0
322 Campak + Pelarut Campak Vial 28,204.00 - - - - 0
323 DPT-HB-Hib Vial 78,991.00 - - - - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
324 DT Vial 17,996.00 - - - - 0
325 Hepatits B Buah 23,991.00 - - - - 0
326 IPV Vial 139,760.00 - - - - 0
327 IPV Vial 144,540.00 - - - - 0
328 MR Vial 141,648.00 - - - - 0
329 Polio+ Dropper Polio Vial 19,954.00 - - - - 0
330 Td Vial 16,995.00 - - - - 0
ANTI RABIES - - 0
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - 0
332 Albendazol 400 mg tablet 258.74 - - 500 - - 0
OBAT GIZI - - 0
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - 3,000 - - 0
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - 0
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - 0
OBAT MALARIA - - 0
336 Blood Slide Kotak 18,509.00 - - - - 0
337 DHP Frimal tablet 2,134.00 9 9 9 - - 0
338 Kelambu GF Buah 61,077.00 - - - - 0
339 Primaquin 15 mg tablet 235.00 - - - - 0
OBAT KIA IBU - - 0
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 10 10 10 - 10 10 10 86,490 10
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - 0
342 Euthyrox 50 mcg tablet 735.00 - - - - 0
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 10 10 10 - 50 - - 10
344 Methylergometrin Injeksi ampul 3,102.00 4 60 64 64 - 200 - - 60
345 MgSO4 20 % fls 3,328.00 12 12 12 - - 12
346 MgSO4 40 % fls 3,796.00 12 12 12 - - 12
OBAT KIA ANAK - - 0
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - 0
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - 0
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 25 25 - 200 50 50 130,000 25
OBAT TB PARU - - 0
350 Box Slide Kotak 41,342.00 - - - - 0
351 Kaca Slide Kotak 30,000.00 - - - - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
352 Kaca Slide Kotak 20,747.00 - - - - 0
353 OAT Kategori Anak Paket 232,518.00 - - - - 0
354 OAT Kategori I Paket 377,900.00 - - - - 0
355 OAT Kategori II Paket 1,259,990.00 - - - - 0
356 Pot Sputum Pot 2,500.00 1,000 1,000 1,000 - - 1000
357 Reagen Ziehl Neelsen Kit 276,000.00 15 15 15 - - 15
358 Sputum Pot Buah 2,950.00 460 460 460 - - 460
359 Tuberkulin Vial 625,900.00 - - - - 0
KUSTA - - 0
360 MDT PB Dewasa Blister 12,569.00 - - - - 0
361 Paket ADRK II Paket 422,980.00 - - - - 0
IMUNISASI - - 0
362 ADS 0,05 ml Buah 1,518.00 - - - - 0
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - 0
364 ADS 0,5 ml Buah 1,127.00 - - - - 0
365 ADS 0,5 ml Buah 1,090.00 - - - - 0
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - 0
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - 0
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - 0
369 ADS 5 ml buah 1,705.00 - - - - 0
370 ADS 5 ml Buah 1,705.00 - - - - 0
371 ADS 5 ml Buah 1,439.00 - - - - 0
372 ADS 5 ml Buah 1,500.00 - - - - 0
373 RCW Unit 2,266,454.00 - - - - 0
374 Safety Box pcs 16,608.00 - - - - 0
375 Safety Box 2,5 ml Buah 12,500.00 - - - - 0
376 Safety Box 5 ml Buah 20,394.00 - - - - 0
377 Vaccine Carrier buah 1,870,000.00 - - - - 0
378 Oseltamivir kapsul 12,969.00 - - - - 0
OBAT DIARE - - 0
379 Garam Oralit Sachet 257.00 100 100 200 200 - 300 - - 100
380 Garam Oralit Sachet 253.00 - - 300 300 300 75,900 200
381 Zink Tablet tablet 551.00 400 500 900 500 400 3,000 1000 1,000 551,000 500
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT HIV/AIDS - - 0
382 Rapid 1 : SD HIV test 11,975.00 - - - - 0
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - 0
384 Rapid Sifilis Ab test 20,400.00 - - - - 0
385 RPR Sifilis test 4,250.00 - - - - 0
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - 0
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - 0
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - 750 750 750 8,981,250 0
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - 0
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - 0
391 Rapid 3 Diagnostar test 13,771.00 - - - - 0
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - 0
393 Rapid Sifilis Trepocheck test 9,697.00 - - - - 0
394 RPR Sifilis test 4,250.00 - - - - 0
OBAT KATARAK - - 0
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - - 0
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - - 0
OBAT PROGRAM - 0
397 L- Zinc botol 31,350.00 10 10 10 - 30 5 5 156,750 10
398 Lagesil Suspensi botol 40,755.00 10 10 10 - 30 5 5 203,775 10
REAGENTIA - - 0
399 Objek Gelas Kotak 50,000.00 6 6 6 - - 6
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - 0
REAGENSIA - 0
401 Larutan Alkohol 96% botol 242,000.00 - - - - 0
402 Larutan Metanol botol 665,500.00 - - - - 0
403 Reagen Benedict botol 484,000.00 - - - - 0
404 Reagen Natrium Sitrat botol 514,250.00 - - - - 0
405 Reagen Receker botol 2,238,500.00 - - - - 0
406 Reagensia Asam Asetat botol 544,500.00 - - - - 0
407 Slide test widal Unit 302,500.00 - - - - 0
BELANJA STICK NARKOBA - 0
JUMLAH PEMBERIAN
I JUMLAH HARGA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - 0
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - 0
PENINGKATAN KESEHATAN MASYARAKAT - - - 0
410 Stick Pemeriksaan Asam Urat Box 1,384,600.00 - - - - 0
411 Stick Pemeriksaan Gula Darah Box 2,632,000.00 - - - - 0
Alkohol 70% 1L Botol 230,000 10 10 8 2 20 20 20 4,600,000
alkohol 70% 300 ml Botol 80,000 10 10 8 2 100 10 10 800,000
One Med Povidone Iodine 60 ml botol 5,186.50 48 48 48 - 200 48 48 248,952
VITAMIN C (Asam Askorbat) tablet 110.00 5,000 2000 2,000 220,000
Fokus Diagnostis Syphilis Test 13,900.00 75 75 75 1,042,500
DHP-Frimal Tablet 2,134.00 9 9 9 19,206
TOTAL 96,851,719

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Lidya Ayu Br.Panjaitan,SKM Dameria Anggelina Saragih AM,Keb
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip: 19830307 2011 01 2 007 Nip: 19840710 2017 04 2 004
DINKES
PUSKESMAS : SUKARAME LAPORAN TRIWULAN : I (II) III IV GFK 2/GFK/3/2020 21-07-2020
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 1,146 - 1,146 432 714 550 300 - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - - - - - - - - -
3 Alopurinol tablet 100 mg tablet 97.00 2,325 500 2,825 291 2,534 - - - -
4 Alopurinol tablet 100 mg tablet 104.00 - - - - - - - - -
5 Ambroxol 15 mg/5 ml botol 6,600.00 47 50 97 16 81 28 50 50 50 330,000.00
6 Ambroxol tab 30 mg tablet 330.00 2,000 - 2,000 24 1,976 - - - -
7 Aminofilin inj 24 mg/ml ampul 2,998.00 60 - 60 - 60 - - - -
8 Aminofilin tablet 200 mg tablet 92.00 200 200 400 - 400 - - - -
9 Amitriptin/Amitriptyline tab/kap/salut 25 mg tablet 168.00 90 - 90 - 90 - - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 - - - - - - - - -
11 tablet 78.00 - 1,500 1,500 322 1,178 - - - -
12 Kaplet 94.00 - - - - - 500 600 600 600 56,400.00
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - - - - - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - - - - - - - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 26 50 76 13 63 - - - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 47 60 107 25 82 - - - -
17 kaptab 261.00 - 2,500 2,500 150 2,350 185 1,000 1000 1,000 261,000.00
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - - - - - -
19 Antasida Tablet box 5,594.00 - - - - - - - - -
20 Antasida Tablet tablet 200.00 2,362 3,000 5,362 3,273 2,089 4,040 2,500 - -
21 Antasida Tab Tablet 355.00 - - - - - - 2,500 2500 2,500 887,500.00
Page 383
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

22 tablet 60.00 - - - - - - - - -

23 botol 2,189.00 68 50 118 36 82 - - - -

+ Polimiksin 10.0003,071.00
IU/g 35 - 35 12 23 15 25 25 25 76,775.00

25 pot 4,540.00 68 - 68 - 68 - - - -
Asam Salisilat 3%

26 3,325.00 - - - - - - - - -
heksaklorofen a
27 Arkine 100 tablet 687.50 - - - - - - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 10 - 10 1 9 - - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 - 200 200 10 190 15 300 300 300 73,500.00
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - - - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 5 - 5 - 5 - - - -
33 Bedak salisil serbuk 2% dus 1,040.00 80 - 80 26 54 - - - -
34 Bedak Salisil Kotak 8,000.00 - - - - - - - - -
35 Betametason krim 0,5 mg/g tube 3,388.00 81 - 81 27 54 34 24 - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - - - - - 25 25 25 33,500.00
37 Ampul 130,999.00 - - - - - - - - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 - - - - - - - - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 80 30 110 20 90 - - - -
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 206 - 206 28 178 - - - -

41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - - - - - - - -
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 18 - 18 15 3 19 400 - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - - - - - -
44 Ceftriaxone 1 g injeksi @ 10 vial vial 38,500.00 - - - - - - - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - - - - - -
tablet salut
46 Cetirizin Hydrochloride 94.00 949 - 949 949 - - - - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - 1,000 1,000 460 540 525 2,000 500 500 50,500.00
Page 384
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 92 50 142 27 115 - - - -
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 - - - - - - - - -

50 165.00 - - - - - - - - -

51 kapsul 770.00 - - - - - 200 200 200 200 154,000.00
52 Codeine 10 mg tablet 600.00 - - - - - - - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 27 - 27 2 25 - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 - 10 10 - 10 - 20 20 20 43,800.00

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 445 100 545 185 360 215 500 500 500 66,500.00
56 tablet 47.00 - - - - - - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 - 50 50 2 48 - - - -
mg/ml
58 Dexamethason inj Ampul 4,500.00 - - - - - - - - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 2,000 1,000 3,000 - 3,000 - - - -
60 Dexamethasone tablet 0,5 mg tablet 154.00 - - - - - - - - -
61 Dekstrofen Syrup Botol 11,550.00 94 - 94 - 94 - - - -
62 Diazepam 2 mg Tablet 86.00 200 - 200 - 200 - - - -
63 Diazepam tablet/kapsul/kaplet 5 mg tablet 114.00 - - - - - - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 - 5 5 - 5 - - - -
65 Diclofenac Sodium 25 mg Tablet 141.00 - - - - - - - - -
66 Diclofenac Sodium 50 mg Tablet 136.00 - - - - - - - - -
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 - - - - - - - - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 - 60 60 - 60 - - - -
69 Difenhidramin injeksi 10 mg/ml ampul 1,228.00 - - - - - - - - -
70 Digoksin tablet 0,25 mg tablet 106.00 - - - - - - - - -
71 Digoksin 0,25 mg Tablet 104.00 - 200 200 - 200 - - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 480 - 480 480 - 100 100 - -
Page 385
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 66 50 116 - 116 - - - -
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 3,221 - 3,221 722 2,499 - - - -
75 Domperidon tablet 10 mg tablet 86.00 - - - - - - - - -
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - 10 10 - 10 - - - -
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 - - - - - - - - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 - - - - - 5 5 - -
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 - - - - - - - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 670 - 670 40 630 - - - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 - - - - - - - - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 53 - 53 - 53 - - - -
83 Eugenol cairan botol 21,091.00 - - - - - - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 - - - - - - - - -
85 Fenobarbital tablet 30 mg tablet 180.00 - - - - - - - - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - - - - - - -
87 tablet 747.00 760 - 760 - 760 - - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 300 - 300 - 300 - - - -
89 ampul 3,867.00 - 30 30 - 30 - - - -
mg/ml
90 Fituno Tab tablet 4,163.10 - - - - - 2,000 2,000 300 300 1,248,930.00
91 Furosemid Inj 10 mg/ml ampul 1,333.00 8 - 8 8 - 11 25 25 25 33,325.00
92 Furosemide tablet 40 mg tablet 77.00 - 200 200 - 200 - - - -
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 - - - - - - - - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 21 12 33 2 31 - - - -
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 20 12 32 5 27 7 15 5 5 22,260.00
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 4,430 - 4,430 215 4,215 - - - -
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 - 20 20 - 20 - - - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 - - - - - 300 300 300 300 73,500.00
99 Griseofulvin tablet 125 mg tablet 232.00 - - - - - - - - -

100 Haldol Decanoas Haloperidol inj 50 mg/ml ampul 101,300.00 - - - - - - - - -
Page 386
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
101 Haloperidol 0,5 mg Tablet 55.00 100 - 100 - 100 - - - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - - - - - - -
103 Hidrokortison krim 2,5 % tube 2,640.00 100 - 100 29 71 - - - -
104 Hidrokortison krim 2,5% tube 2,475.00 - - - - - - - - -
105 Hustab Syrup botol 11,550.00 61 50 111 36 75 40 50 50 50 577,500.00
106 Hustab P Tablet 8 mg Tablet 256.67 1,500 - 1,500 180 1,320 - - - -
107 Hustab Tablet tablet 437.00 - 300 300 300 - 400 1,200 1200 1,200 524,400.00
tablet salut
108 Ibuprofen tab/kaps/kapl 200 mg 108.00 - 2,500 2,500 - 2,500 - - - -
selaput
tablet salut
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg 105.00 2,261 - 2,261 1,442 819 - - - -
selaput
110 Ibuprofen 200 mg Tablet 550.00 - - - - - - 700 700 700 385,000.00

111 Ibuprofen 400 mg Tablet 800.00 - 300 300 105 195 130 2,000 300 300 240,000.00
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 50 50 100 15 85 - - - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - - - - - - -
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 264 - 264 - 264 - - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 1,830 - 1,830 240 1,590 - - - -
116 tablet 63.00 1,980 200 2,180 70 2,110 - - - -
117 Kanamycin 1 gr inj vial 10,768.00 - - - - - - - - -
118 Kaptopril 12,5 mg tablet 68.00 450 200 650 50 600 - 500 500 500 34,000.00
119 Ketokenazol tablet 200 mg tablet 278.00 1,110 - 1,110 1,010 100 1,250 200 - -
120 Ketokonazol tablet 200 mg tablet 297.00 - - - - - - - - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 200 - 200 - 200 - - - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - - - - - - - -
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - - - - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 - - - - - - - - -
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - 50 50 - 50 - - - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - - - - - - - -

127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 8,890 - 8,890 1,863 7,027 - - - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - - 2,800 2,800 - -
Page 387
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
129 Klorfeniramin maleat tablet 25.00 - - - - - - 3,000 3000 3,000 75,000.00
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 1,360 - 1,360 - 1,360 - - - -
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 - - - - - - - - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 - 30 30 - 30 - - - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 - 200 200 - 200 - - - -
134 Meloksikam 7,5 mg tablet 795.68 - - - - - 1,000 1,000 - -
135 Meloxicam tab15 mg tablet 1,438.80 370 500 870 495 375 611 500 500 500 719,400.00
136 Meloxicam 15 mg Tablet 980.00 - - - - - - - - -
tablet salut
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan 106.00 170 500 670 440 230 550 2,000 500 500 53,000.00
selaput
strip/blister (G)
138 tablet 137.00 - - - - - 1,200 1,200 - -
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - - - - - - 1,000 1000 1,000 146,000.00
140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - - - - - -

141 Methyl prednisolone 125 mg Dos 8,143.00 - - - - - - - - -
tablet salut
142 Metil Ergometrin tablet Salut Selaput 0,125 mg 222.00 150 - 150 40 110 - - - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - - - - - -
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 490 - 490 6 484 - - - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - - - - - - - - -
146 Metronidazole tablet 500 mg tablet 264.00 724 - 724 354 370 436 500 500 500 132,000.00
147 MgSO4 20 % botol 13,500.00 5 6 11 5 6 - - - -
148 MgSO4 40 % botol 13,500.00 5 - 5 5 - 5 2 - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 53 48 101 52 49 65 50 48 48 172,080.00
150 NaCl 0,9 % 500 ml botol 6,840.00 53 - 53 7 46 - - - -
151 tablet 132.00 3,800 - 3,800 1,571 2,229 - - - -
25 mg
152 tablet 127.00 2,800 - 2,800 - 2,800 - - - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 850 - 850 203 647 - - - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 500 - 500 10 490 - - - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - - - - - - - - -
156 Obat Anti Tuberculosis FDC Kategori I paket 408,810.00 - - - - - - - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - - - - - -
Page 388
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
158 Obat Anti Tuberculosis FDC Kategori II paket 1,362,789.00 - - - - - - - - -
159 Obat Anti Tuberculosis FDC Kategori II Paket 1,454,232.00 - - - - - - - - -
160 Oksitosin injeksi 10 IU/ml ampul 1,900.00 - - - - - 50 50 - -
161 Omeprazol Tab Tablet 650.00 - 200 200 65 135 80 500 200 200 130,000.00
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 - - - - - - - - -
163 Paracetamol Tab 500 mg tablet 290.00 - - - - - - - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 1,668 3,000 4,668 873 3,795 - - - -
165 bottle 6,981.00 25 - 25 6 19 - - - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 - 30 30 11 19 13 50 10 10 11,840.00
167 Pehacain Injeksi ampul 3,113.06 90 - 90 73 17 - - - -
168 Pehacain Injeksi Ampul 3,113.05 - 100 100 40 60 - - - -
169 Pehamoksil Tablet 500 mg Tablet 759.00 967 - 967 967 - - - - -
170 Pehastan 500 mg tablet 445.50 1,500 1,000 2,500 1,650 850 2,035 2,500 1500 1,500 668,250.00
171 Pehavral tablet 935.00 - 500 500 500 - 500 500 500 500 467,500.00
172 Perak sulfadiazin krim 1% tube 20,700.00 22 10 32 4 28 5 3 - -
173 Peridol Syrup 60 ml botol 19,800.00 - - - - - - - - -
174 botol 124,355.00 2 - 2 1 1 1 1 1 1 124,355.00
0,2 %
175 Phaproxin 500 mg tablet 880.00 - 50 50 - 50 - 100 100 100 88,000.00
176 tablet 302.00 996 - 996 996 - - - - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 - 100 100 - 100 - 100 100 100 32,200.00
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 18 - 18 15 3 - - - -
179 Pirantel Pamoat syrup botol 10,778.00 - - - - - - - - -
180 Tablet 124.00 6,442 - 6,442 6,325 117 - - - -
(HCl)
181 tablet 129.00 - - - - - - - - -
(HCl)
182 Prednison tablet 5 mg tablet 76.00 - - - - - - 1,000 1000 1,000 76,000.00
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 1,495 - 1,495 1,495 - 1,850 1,000 - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 4,204 - 4,204 1,344 2,860 - - - -
185 Pyridol Syrup 60 ml botol 18,150.00 37 - 37 36 1 - - - -
186 Ranitidin 150 mg Tablet tablet 660.00 2,680 - 2,680 500 2,180 - - - -
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 - - - - - - - - -
188 Ranitidin Injeksi 25 mg/ml Ampul 1,155.00 - - - - - - - - -
Page 389
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
189 Retinol/ Vit A 100.000 UI capsule 304.00 30 - 30 - 30 - - - -
190 Retinol/ Vit A 200.000 UI capsule 543.99 - - - - - - - - -
191 Ringer Laktat 500 ml botol 7,630.00 - - - - - - - - -
192 Roeko Endo Frost 200 ml botol 352,000.00 - - - - - - - - -
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 1,857 - 1,857 33 1,824 - - - -
194 Salbutamol 2 mg tab tablet 67.00 - 200 200 - 200 - - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 1,568 - 1,568 162 1,406 - - - -
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 - - - - - - - - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 - - - - - - - - -
198 pot 2,654.00 49 - 49 8 41 - - - -
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - - - - - - 300 300 300 363,000.00
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - - - - - - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 9 - 9 9 - - - - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 1,680 - 1,680 270 1,410 335 600 600 600 66,000.00
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 - - - - - - - - -
tablet salut
204 Simvastatin Tablet/Kaplet/Salut selaput 20 mg 214.00 400 - 400 400 - 450 500 - -
selaput
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - - - - - - - -

206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - - - - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 220 - 220 150 70 - - - -
208 tablet 84.00 3,827 - 3,827 481 3,346 - - - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - - - - - - - - -

210 93.00 100 - 100 - 100 - - - -
211 Vapril 25 mg tablet 193.00 - 500 500 - 500 - - - -

212 box 6,550.00 - - - - - - - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 892 2,000 2,892 2,389 503 2,945 3,000 1500 1,500 184,500.00
214 vitamin B12 injeksi 500 mcg/mL ampul 1,136.00 - - - - - - - - -
215 Vitamin B12 tablet 50 mcg tablet 52.00 2,382 - 2,382 1,014 1,368 1,250 1,000 1000 1,000 52,000.00
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - - - - - -
Page 390
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
217 Vitamin B6 10 mg tablet 138.00 - - - - - - - - -
218 9,646.00 - - - - - - - - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 17 - 17 17 - - - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 - - - - - - 28,000 28000 28,000 10,416,000.00
221 Hemafort tablet 834.90 2,100 500 2,600 500 2,100 650 2,000 2000 2,000 1,669,800.00

222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 40 - 40 - 40 - - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 - - - - - - 200 200 200 64,800.00
224 Kapsul 581.00 30 - 30 - 30 - 1,400 1400 1,400 813,400.00
IU
225 Allkohol 70% bottle 28,733.33 - - - - - - - - -
226 Alkohol 70% 1L botol 28,750.00 - - - - - - - - -
227 Arm sling L buah 17,424.00 - 1 1 - 1 - - - -
228 Arm sling M buah 17,424.00 - 2 2 - 2 - - - -
229 Arm sling S buah 17,424.00 - 1 1 - 1 - - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - - - - - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 - - - - - - - - -
232 Aximed Syringe 1 cc Dus 103,750.00 - - - - - - 10 10 10 1,037,500.00
233 Aximed Syringe 3 cc Dus 103,125.00 1 5 6 2 4 - - - -
234 Blood Lancet box 16,022.60 1 - 1 - 1 - - - -
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - 12 12 12 - - - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - - - - - - -
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - 12 12 12 - 15 20 12 12 511,980.00
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - 12 12 12 - - - - -
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - - - - - - - - -
Page 391
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - - - - - - -
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 24 - 24 - 24 30 45 12 12 496,380.00
245 Catgut Plain 3/0 DS 19 mm Sachet 40,137.40 - - - - - - - - -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - - - - - - - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 50 - 50 - 50 - - - -
248 Catheter Tro-Venocath, Sine 22 G pcs 12,631.00 - - - - - - - - -
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - - - - - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - 20 20 20 - - - - -
253 Chirurgic Gloves, size 8 pcs 9,525.12 - 10 10 10 - - - - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 9 - 9 - 9 - - - -
255 Dermafix T 10x12cm pcs 6,939.90 - - - - - - - - -
256 Examination Gloves size L box 58,564.00 3 1 4 1 3 3 5 3 3 175,692.00
257 Examination Gloves size M box 58,564.00 3 1 4 1 3 3 5 5 5 292,820.00
258 Examination Gloves size S box 58,564.00 - - - - - 3 3 3 3 175,692.00
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - - - - - - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 - - - - - - - - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - - - - - -
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - - - - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - - - - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - - - - -
267 Hb Sahli set 96,800.00 - - - - - - - - -
268 Hidrogen Peroxide 3% botol 3,864.00 5 3 8 3 5 - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - - - - - -
270 Infuset pcs 6,166.16 - 25 25 25 - - 25 25 25 154,154.00
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - - - - - - - -
Page 392
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
275 Kapas pembalut 250 gr roll 13,733.33 - - - - - - - - -
276 Kapas pembalut 250 gr roll 13,750.00 - 2 2 2 - 4 5 5 5 68,750.00
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - - - - - - - - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 186 100 286 100 186 - - - -
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 176 - 176 - 176 - - - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - - - - - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 10 - 10 - 10 - - - -
282 Lysol 1 liter botol 47,150.00 3 5 8 5 3 - - - -
283 Masker Ear Loop Box 20,202.00 - 4 4 4 - 6 10 - -
284 Masker Tie on Box 19,869.00 - 1 1 1 - 3 10 - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - - - - - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - - - - - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - - - - - - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - - - - - -
289 Onemed Alcohol Swab botol 11,000.00 - - - - - - - - -
290 Onemed Blood Lancet box 16,022.60 - - - - - - - - -
291 Onesept 500 ml botol 30,360.00 - - - - - - - - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 2 - 2 - 2 - - - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - - - - - -
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 1 - 1 - 1 - - - -
295 Safeglove Examination Gloves L box 39,182.00 - - - - - - - - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - - - - - - - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 - - - - - - 12 12 12 302,220.00
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - 12 12 12 - 16 24 - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - - - - - - -
300 Stera Infuset anak pcs 3,850.00 - - - - - - - - -
301 Surgical Mask Earloop box 18,150.00 - - - - - - 5 5 5 90,750.00
302 Surgical Mask Tie On box 18,150.00 - - - - - - 5 5 5 90,750.00
Page 393
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
303 Swab 2 ply dus 14,040.84 - - - - - - - - -
304 Syringe 10 cc dus 167,266.70 - - - - - - - - -
305 Syringe 1cc pcs 1,045.80 - - - - - - - - -
306 Syringe 1cc dus 106,523.56 - - - - - - - - -
307 Syringe 3cc dus 107,421.38 - - - - - - - - -
308 Syringe 5cc dus 119,090.61 - - - - - - - - -
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - - - - - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - - - - - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - - - - - -
312 Tp. Disposable Syringe 5 cc pcs 892.78 - - - - - - - - -

313 pcs 7,072.50 10 - 10 - 10 - - - -
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - - - - - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - - - - - -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - - - - - -
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 - - - - - - - - -
318 Urine bag steril (t-valve) pcs 3,300.00 5 - 5 - 5 - - - -
PEMERIKSAAN HIV - -
319 HIV Device Box 707,143.00 - - - - - - 14 14 14 9,900,002.00
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142 - - - - - - - - -
VAKSIN - -
321 BCG +Pelarut BCG Vial 61,996.00 6 - 6 - 6 - - - -
322 Campak + Pelarut Campak Vial 28,204.00 - - - - - - - - -
323 DPT-HB-Hib Vial 78,991.00 4 - 4 - 4 - - - -
324 DT Vial 17,996.00 - - - - - - - - -
325 Hepatits B Buah 23,991.00 20 - 20 - 20 - - - -
326 IPV Vial 139,760.00 5 - 5 - 5 - - - -
327 IPV Vial 144,540.00 - - - - - - - - -
Page 394
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
328 MR Vial 141,648.00 16 - 16 - 16 - - - -
329 Polio+ Dropper Polio Vial 19,954.00 1 - 1 - 1 - - - -
330 Td Vial 16,995.00 15 - 15 - 15 - - - -
ANTI RABIES - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - - - - - -
OBAT FILARIASIS - -
332 Albendazol 400 mg tablet 258.74 - - - - - - - - -
OBAT GIZI - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 17,940 - 17,940 - 17,940 - - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - - - - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - - - - - -
OBAT MALARIA - -
336 Blood Slide Kotak 18,509.00 - - - - - - 5 5 5 92,545.00
337 DHP Frimal tablet 3,498.00 - - - - - - - - -
338 Kelambu GF Buah 61,077.00 - - - - - - - - -
339 Primaquin 15 mg tablet 235.00 80 - 80 - 80 - 50 - -
OBAT KIA IBU - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - - - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 5 - 5 - 5 - - - -
342 Euthyrox 50 mcg tablet 735.00 - - - - - - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - - - - - - 10 10 10 36,850.00
344 Methylergometrin Injeksi ampul 3,102.00 30 - 30 - 30 - - - -
345 MgSO4 20 % fls 3,328.00 - - - - - - - - -
346 MgSO4 40 % fls 3,796.00 - - - - - - - - -
OBAT KIA ANAK - -
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - - - - -
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - 30 30 - 30 - - - -
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 - 25 25 - 25 - 25 25 25 65,000.00
OBAT TB PARU - -
350 Box Slide Kotak 41,342.00 - - - - - - - - -
Page 395
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
351 Kaca Slide Kotak 30,000.00 - - - - - - - - -
352 Kaca Slide Kotak 20,747.00 - - - - - - - - -
353 OAT Kategori Anak Paket 232,518.00 - - - - - - - - -
354 OAT Kategori I Paket 377,900.00 - - - - - - - - -
355 OAT Kategori II Paket 1,259,990.00 - - - - - - - - -
356 Pot Sputum Pot 2,500.00 - - - - - - 1,000 1000 1,000 2,500,000.00
357 Reagen Ziehl Neelsen Kit 276,000.00 - 13 13 13 - - - - -
358 Sputum Pot Buah 2,950.00 200 1,000 1,200 1,000 200 - - - -
359 Tuberkulin Vial 625,900.00 - - - - - - - - -
KUSTA - -
360 MDT PB Dewasa Blister 12,569.00 - - - - - - - - -
361 Paket ADRK II Paket 422,980.00 - - - - - - - - -
IMUNISASI - -
362 ADS 0,05 ml Buah 1,518.00 - - - - - - - - -
363 ADS 0,5 (Oneject) Buah 1,621.00 5 - 5 - 5 - - - -
364 ADS 0,5 ml Buah 1,127.00 - - - - - - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - - - - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 300 - 300 - 300 - 300 - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - - - - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - - - - - -
369 ADS 5 ml buah 1,705.00 - - - - - - - - -
370 ADS 5 ml Buah 1,705.00 - - - - - - - - -
371 ADS 5 ml Buah 1,439.00 - - - - - - - - -
372 ADS 5 ml Buah 1,500.00 - - - - - - - - -
373 RCW Unit 2,266,454.00 - - - - - - - - -
374 Safety Box pcs 16,608.00 22 25 47 25 22 - - - -
375 Safety Box 2,5 ml Buah 12,500.00 - - - - - - - - -
376 Safety Box 5 ml Buah 20,394.00 - 25 25 25 - - - - -
377 Vaccine Carrier buah 1,870,000.00 1 - 1 - 1 - - - -
Page 396
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
OBAT FLU BURUNG - -
378 Oseltamivir kapsul 12,969.00 - - - - - - - - -
OBAT DIARE - -
379 Garam Oralit Sachet 257.00 - - - - - - - - -
380 Garam Oralit Sachet 253.00 390 200 590 200 390 - - - -
381 Zink Tablet tablet 551.00 1,363 1,000 2,363 1,000 1,363 - - - -
OBAT HIV/AIDS - -
382 Rapid 1 : SD HIV test 11,975.00 - - - - - - - - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - - - - - -
384 Rapid Sifilis Ab test 20,400.00 - - - - - - - - -
385 RPR Sifilis test 4,250.00 - - - - - - - - -
OBAT HEPATITIS - -
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - - - - - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - - - - - -
Reagensia/ Alat - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - - - - - - -
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - - - - - -
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - - - - - -
391 Rapid 3 Diagnostar test 13,771.00 - - - - - - - - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - - - - - -
393 Rapid Sifilis Trepocheck test 9,697.00 - - - - - - 75 75 75 727,275.00
394 RPR Sifilis test 4,250.00 - - - - - - - - -
OBAT KATARAK - -
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - 40 40 - 40 - 25 - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - 2 2 - 2 - 2 - -
OBAT PROGRAM - -
397 L- Zinc botol 31,350.00 - - - - - - - - -
398 Lagesil Suspensi botol 40,755.00 - - - - - - - - -
REAGENTIA - -
Page 397
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
399 Objek Gelas Kotak 50,000.00 - 5 5 5 - - - - -
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - - - - - -
REAGENSIA - -
401 Larutan Alkohol 96% botol 242,000.00 - - - - - - - - -
402 Larutan Metanol botol 665,500.00 - - - - - - - - -
403 Reagen Benedict botol 484,000.00 - - - - - - - - -
404 Reagen Natrium Sitrat botol 514,250.00 - - - - - - - - -
405 Reagen Receker botol 2,238,500.00 - - - - - - - - -
406 Reagensia Asam Asetat botol 544,500.00 - - - - - - - - -
407 Slide test widal Unit 302,500.00 - - - - - - - - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - - - - - -
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - - - - - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - - - - - - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - - - - - -
Asam Askorbat (Vit C) tab 50 mg tablet 110.00 1,000 1000 1,000 110,000.00
Fokus Diagnostis Syphilis Test 13,900.00 50 50 50 695,000.00
Fokus New HIV 1/2 Test 13,235.00 500 500 500 6,617,500.00
DHP-Frimal Tablet 2,134.00 9 9 9 19,206.00
One Med Povidone Iodine 60 ml botol 5,186.50 10 10 10 51,865.00
Alkohol 70% 1L botol 230,000.00 3 3 3 690,000.00
TOTAL 48,242,446
Diketahui: Diketahui: Yang Menyerahkan Diketahui : Yang Meminta

Kepala Dinas Kesehatan Kabid. Sumber Daya Kesehatan Kasie Farmasi Kepala Puskesmas Pengelola Obat
dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Sri Wanti, SKM, M.Kes ASMAWATI SITORUS, A.Md
Page 398
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 Nip.19860602 201101 2 010 NIP.19880402 201505 2 001
Page 399
0
0
500
0
50
0
0
200
0
0
1500
0
0
50
60
2500
0
0
3000
0
Page 400
0
50
0
0
0
200
0
0
0
0
0
0
30
0
0
0
0
0
0
1000
Page 401
50
0
0
0
10
100
50
0
1000
0
0
0
0
5
0
0
0
60
0
0
200
Page 402
50
0
0
10
0
0
0
0
0
0
0
0
30
0
0
200
0
12
12
20
0
0
Page 403
0
0
0
0
50
0
300
2500
0
300
50
0
200
0
200
0
0
0
0
0
0
50
0
0
0
Page 404
0
0
0
30
200
0
500
0
500
0
0
0
0
6
0
48
0
0
0
0
0
0
Page 405
0
0
0
200
0
0
3000
30
0
100
0
1000
500
10
0
50
100
0
0
0
0
0
0
0
0
0
0
Page 406
0
0
0
0
0
200
0
0
0
0
0
0
0
0
0
500
2000
0
0
0
Page 407
0
0
0
0
500
0
0
0
1
2
1
0
0
0
5
0
12
0
0
12
0
0
12
0
Page 408
0
0
0
0
0
0
0
0
0
20
10
0
0
1
1
0
0
0
0
0
0
0
0
0
0
3
0
25
0
0
Page 409
0
0
0
2
0
100
0
0
0
5
4
1
0
0
0
0
0
0
0
0
0
0
0
0
0
12
0
0
0
0
Page 410
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 411
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
30
25
0
0
Page 412
0
0
0
0
0
0
13
1000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
25
0
25
0
Page 413
0
0
0
0
200
1000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 414
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 415
DINKES
PUSKESMAS : TANJUNG PASIR LAPORAN TRIWULAN : I (II) III IV IFK 1/GFK/3/2020 10-Jul-20
KECAMATAN : KUALUH SELATAN PERMINTAAN TRIWULAN : I II (III) IV PUSKESMAS
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18

1 capsule 357.00 - - - - - -
200 mg
2 Acyclovir 200 mg Tablet 1,050.00 - - - - - - - - -
3 Alopurinol tablet 100 mg tablet 97.00 1,360 1,000 2,360 630 1,260 - - - -
5 Ambroxol 15 mg/5 ml botol 6,600.00 - - - - - -
6 Ambroxol tab 30 mg tablet 330.00 - - - - - -
7 Aminofilin inj 24 mg/ml ampul 2,998.00 23 - 23 23 - -
8 Aminofilin tablet 200 mg tablet 92.00 - - - - - -
10 Amlodipine Besilat tablet 5 mg tablet 73.00 - - - - - - - -
11 tablet 78.00 310 - 310 - 310 - -
12 Kaplet 94.00 - - - - - -
13 Amoksisilin 100 mg/mL botol 13,500.00 - - - - - -
14 Amoksisilin 250 mg kapsul Kapsul 203.00 - - - - - - -
15 Amoksisilin sir kering 125 mg/5 ml botol 6,600.00 58 - 58 40 18 - - - -
16 Amoksisilin sirup kering 250 mg/5 ml botol 3,670.00 - - - - 120 120 120 440,400.00
17 kaptab 261.00 1,466 1,000 2,466 2,466 - - - -
18 Ampisilin / Ampicilin serbuk injeksi 1000 mg vial 8,649.00 - - - - - -
20 Antasida Tablet tablet 200.00 4,684 4,000 8,684 1,800 6,884 - - - -
21 Antasida Tab Tablet 355.00 - - - - - 3,000 3,000 3,000 1,065,000.00
22 tablet 60.00 - - - - - -
Page 416
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
23 botol 2,189.00 72 100 172 51 121 100 50 50 109,450.00

+ Polimiksin 10.000
3,071.00
IU/g - - - - - -

25 pot 4,540.00 - - - - - -
Asam Salisilat 3%

26 3,325.00 - - - - - -
heksaklorofen ria
27 Arkine 100 tablet 687.50 - - - - - -
28 Asam Mefenamat 500 mg tablet 242.89 - - - - - - - -
29 Asam Traneksamat Injeksi 50 mg/ml ampul 1,813.00 - - - - - -
30 Asiklovir tablet/kapsul/kaplet 200 mg tablet 245.00 1,080 - 1,080 374 706 - - - -
31 Asiklovir Tablet 200 mg Tablet 560.18 - - - - - -
32 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) ampul 1,540.00 - - - - - - -
33 Bedak salisil serbuk 2% dus 1,040.00 - - - - - - -
34 Bedak Salisil Kotak 8,000.00 - - - - 10 10 10 80,000.00
35 Betametason krim 0,5 mg/g tube 3,388.00 34 24 58 25 33 - - - -
36 Betametason/Betamethasone Valerate krim 0,1% tube 1,340.00 - - - - - 25 25 25 33,500.00
37 Ampul 130,999.00 - - - - - - -
(i.m)
38 Biosave Serum Anti Bisa Ular A.B.U 1 gr inj vial 512,204.00 1 - 1 1 - -
kaptab
39 Bisakodil/Bisacodyl tablet/kapsul/kaplet salut 5 mg salut 327.00 70 - 70 110 70 150 60 60 19,620.00
selaput
40 Bufacetine Kloramfenikol salep kulit 2% tube 3,107.00 63 - 63 63 - - - -
41 Bufacetin Kloramfenikol Salep 2 % tube 3,138.00 - - - - - -
42 Cefadroxil 500 mg kapsul kapsul 1,202.34 - - - - - -
43 Cefotaxime sodium 1 gr vial 7,342.50 - - - - - -
45 Ceftriaxone Injeksi 1 g vial 8,332.50 - - - - - -
tablet
46 Cetirizin Hydrochloride salut 94.00 660 - 660 - 660 - - - -
selaput
47 Cetirizine tablet 10 mg tablet 101.00 - 300 300 300 800 800 800 80,800.00
48 Cetirizine sirup 5 mg/5ml botol 2,973.00 - - - - - -
49 Chloramphenicol kapsul 250 mg Kapsul 660.00 400 - 400 200 200 - - - -
tablet
50 salut 165.00 - - - - - -
selaput
Page 417
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
51 kapsul 770.00 1,270 - 1,270 - 1,270 1,000 1,000 1,000 770,000.00
52 Codeine 10 mg tablet 600.00 - - - - - -
53 Cotrimoksazole 240 mg / 5 ml suspensi bottle 6,600.00 - - - - - -
54 kombinasi tiap 5 ml suspensi: sulfametoksazol 200 mg + botol 2,190.00 98 - 98 98 - - - -

55 kombinasi: sulfametoksazol 400 mg + trimetoprim 80 tablet 133.00 983 - 983 983 - - - -
56 tablet 47.00 - - - - - - - -
Deksametason sodium
57 phosphate/Dexamethasone/Deksametason injeksi 5 ampul 1,152.00 480 480 960 960 900 900 900 1,036,800.00
mg/ml
58 Dexamethason inj Ampul 4,500.00 105 - 105 105 - -

59 Dexametason Tablet 0,5 mg Tablet 33.00 849 500 1,349 438 911 2,000 2,000 2,000 66,000.00
61 Dekstrofen Syrup Botol 11,550.00 68 - 68 45 23 - - - -
62 Diazepam 2 mg Tablet 86.00 100 - 100 100 - - - -
64 Diazepam injeksi 5 mg/ml ampul 1,822.00 7 - 7 7 - - - -
65 Diclofenac Sodium 25 mg Tablet 141.00 1,000 1,000 2,000 2,000 1,000 1,000 1,000 141,000.00
66 Diclofenac Sodium 50 mg Tablet 136.00 - - - - 1,000 1,000 1,000 136,000.00
67 Difenhidramin injeksi 10 mg/ml (HCl) ampul 1,115.00 90 - 90 5 85 - - - -
68 Difenhidramin Injeksi 10 mg/ ml ampul 1,151.00 25 - 25 25 60 60 60 69,060.00
70 Digoksin tablet 0,25 mg tablet 106.00 500 - 500 - 500 - -
71 Digoksin 0,25 mg Tablet 104.00 - - - - - -
72 Doksisiklin/Doxycycline hyclate tab/kaps/kapl 100 mg capsule 264.00 - - - - - -
Botol
73 Domperidon Suspensi 5 mg/5 ml 2,781.00 51 - 51 - 51 - - - -
Plastik
74 Domperidon tablet/kapsul/kaplet 10 mg tablet 95.00 1,759 - 1,759 552 1,207 - - - -
75 Domperidon tablet 10 mg tablet 86.00 - - - - - -
76 Dulcolax Bisakodil suppositoria 10 mg supp 5,900.00 - - - - - -
77 Dulcolax Bisakodil suppositoria 5 mg supp 6,000.00 - - - - - -
78 Epinefrin (Adrenalin) injeksi 0,1% Ampul 1,408.00 100 - 100 100 - -
Page 418
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 57 - 57 1 56 - - - -
kaptab
80 Eritromisin kapl 500 mg salut 765.00 400 - 400 - 400 - - - -
selaput
81 Eritromisin kaplet 500 mg kaplet 785.00 100 - 100 100 - -
82 Eritromisin sirup kering 200 mg/ 5 ml botol 6,303.00 100 - 100 13 87 - - - -
83 Eugenol cairan botol 21,091.00 2 - 2 2 - - - -
84 Fenobarbital tablet 30 mg tablet 165.00 1,000 - 1,000 - 1,000 - -
86 Fenol Gliserol Tetes Telinga botol 2,764.00 - - - - - -
87 tablet 747.00 - - - - - -
gula 10 mg
88 Fitomenadion ( Vitamin K) Tablet 10 mg Tablet 797.00 - - - - - -
89 ampul 3,867.00 30 - 30 - 30 30 30 30 116,010.00
mg/ml
91 Furosemid Inj 10 mg/ml ampul 1,333.00 - - - - - - -
92 Furosemide tablet 40 mg tablet 77.00 700 200 900 900 300 200 200 15,400.00
93 Gentamisin injeksi 40 mg/ ml ampul 3,556.00 5 - 5 5 - -
94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - - - - - - - -
95 gentamisin/gentamycin sulfate tetes mata 0,3% botol 4,452.00 22 - 22 22 - -
96 Glibenklamid/ Glibenclamide tablet/kapsul/kaplet 5 mg kaptab 125.00 2,110 - 2,110 970 1,140 1,000 1,000 1,000 125,000.00
97 Glukosa Larutan Infus 5 % 500 ml botol 7,363.00 14 - 14 14 - - - - -
98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 - - - - - - -
99 Griseofulvin tablet 125 mg tablet 232.00 1,100 - 1,100 900 200 - -

101 Haloperidol 0,5 mg Tablet 55.00 1,440 - 1,440 1,000 440 - -
102 Hidroklorotiazid tab 25 mg tablet 163.00 - - - - 100 100 100 16,300.00
105 Hustab Syrup botol 11,550.00 43 50 93 50 43 50 50 50 577,500.00
106 Hustab P Tablet 8 mg Tablet 256.67 - 1,500 1,500 1,500 1,000 900 900 231,003.00
107 Hustab Tablet tablet 437.00 - - - - - 1,200 1,200 1,200 524,400.00
tablet
108 Ibuprofen tab/kaps/kapl 200 mg salut 108.00 - 700 700 700 2,000 700 -
tablet
selaput
109 Ibuprofen tablet/Kapsul/Kaplet 200 mg salut 105.00 1,690 - 1,690 1,500 190 - - -
selaput
Page 419
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
110 Ibuprofen 200 mg Tablet 550.00 - - - - - - - -
111 Ibuprofen 400 mg Tablet 800.00 300 300 600 125 475 1,000 500 500 400,000.00
112 Ibuprofen suspensi 100 mg/5 ml botol 2,601.00 87 - 87 86 1 - - - -
113 Ibuprofen susp 100 mg/5 ml botol 2,776.00 - - - - - -
114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - - - - - -
115 Kalsium Karbonat tablet/kapsul/kaplet 500 mg Kaplet 430.00 - - - - - -

116 tablet 63.00 650 - 650 200 450 1,000 700 700 44,100.00
118 Kaptopril 12,5 mg tablet 68.00 500 500 1,000 1,000 - - - -
119 Ketokenazol tablet 200 mg tablet 278.00 - - - -
120 Ketokonazol tablet 200 mg tablet 297.00 700 - 700 - 700 - - - -
121 Kloramfenicol kapsul 250 mg Capsule 320.00 670 - 670 670 - - - -
122 Kloramfenikol kapsul 250 mg Kapsul 660.00 - - - - - -
123 Kloramfenikol Salep 2% tube 3,349.00 - - - - - -
124 Kloramfenikol salep mata 1 % Tube 2,007.00 30 - 30 - 30 24 24 24 48,168.00
Botol
125 Kloramfenikol suspensi 125 mg/ 5 ml 4,843.00 - - - - - -
Plastik
126 Kloramfenikol suspensi 125 mg/ 5 ml botol 5,168.00 - - - - - -
127 Klorfeniramina Maleat (CTM) tablet 4 mg Tablet 43.00 4,397 - 4,397 2,711 1,686 - -
128 Klorfeniramin Maleat tablet 4 mg Tablet 23.00 - - - - - -
129 Klorfeniramin maleat tablet 25.00 - - - - 2,000 2,000 2,000 50,000.00
130 Lansoprazole/lansoprazol tablet/kaplet 30 mg capsule 303.00 - 800 800 800 242,400.00
131 Lansoprazole kapsul 30 mg kapsul 1,283.75 640 900 1,540 - 1,540 - - - -
132 Lidocaine Injeksi 2 % ampul 1,203.00 50 50 100 100 - - - -
133 Loperamid 2 mg (Bidium 2 mg) Tablet 260.00 470 - 470 - 470 500 300 300 78,000.00
134 Meloksikam 7,5 mg tablet 795.68 - - - - - - -
135 Meloxicam tab15 mg tablet 1,438.80 300 500 800 220 580 500 300 300 431,640.00
136 Meloxicam 15 mg Tablet 980.00 810 - 810 810 - -
137 tablet/kapsul/kaplet/kaptab 500 mg, kemasan salut 106.00 480 500 980 1,000 480 500 500 500 53,000.00
138 tablet 137.00 607 500 1,120 - 1,120 500 500 500 68,500.00
mg
139 Metilprednisolon tablet 4 mg tablet 146.00 - 700 700 700 102,200.00

Page 420
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
tablet
142 Metil Ergometrin tablet Salut Selaput 0,125 mg salut 222.00 - - - - - -
selaput
143 Metilergometrin tablet 0,125 mg tablet 237.00 - - - - 500 500 500 118,500.00
144 (hcl)/metoclopramide/metoklopramid tab/kaps/kapl 10 tablet 80.00 - - - - - -
mg
145 Metronidazol suspensi 125 mg/5 mL botol 3,950.00 - - - - - -
146 Metronidazole tablet 500 mg tablet 264.00 1,197 - 1,197 183 1,014 - - - -
147 MgSO4 20 % botol 13,500.00 12 - 12 12 - - - -
148 MgSO4 40 % botol 13,500.00 12 - 12 12 - - - -
149 Miconazole nitrate/miconazole/mikonazol krim 2% tube 3,585.00 33 - 33 - 33 24 24 24 86,040.00
150 NaCl 0,9 % 500 ml botol 6,840.00 20 - 20 7 13 - - - -
151 tablet 132.00 530 - 530 570 530 - -
25 mg
152 tablet 127.00 700 - 700 330 370 - - - -
50 mg
153 Nifedipin tablet/kapsul 10 mg tablet 110.00 - - - - - -
154 Nistatin Tablet/ kaplet salut gula 500.000 IU tablet 830.00 - - - - - -
155 Nystatin tablet 500.000 IU Tablet 886.00 - - - - - -
157 Obat Anti Tuberculosis FDC Kategori I Paket 436,241.00 - - - - - -
161 Omeprazol Tab Tablet 650.00 240 200 440 910 - 470 - - - -
162 Oxytocin/Oksitosin inj 10 iu/ml Ampul 1,199.00 10 - 10 10 - - -
163 Paracetamol Tab 500 mg tablet 290.00 2,280 - 2,280 - 2,280 - - - -
164 Paracetamol kaplet 500 mg kaplet 165.00 5,200 5,200 10,400 5,802 4,598 - - - -
165 bottle 6,981.00 - - - - - - - - -
(60 ml/0,6 ml) (G)
166 Paracetamol/ Parasetamol sirup 120 mg / 5 ml tablet 1,184.00 72 50 122 178 - 56 - - - -
167 Pehacain Injeksi ampul 3,113.06 - - - - - -
168 Pehacain Injeksi Ampul 3,113.05 134 - 279 10 124 200 200 200 622,610.00
169 Pehamoksil Tablet 500 mg Tablet 759.00 - - - - - - - -
170 Pehastan 500 mg tablet 445.50 1,980 1,000 2,980 - 2,980 1,500 1,500 1,500 668,250.00
171 Pehavral tablet 935.00 670 1,000 1,670 - 1,670 1,500 `1500 - -
172 Perak sulfadiazin krim 1% tube 20,700.00 5 - 5 5 - 5 - - -
173 Peridol Syrup 60 ml botol 19,800.00 - - - - 24 24 24 475,200.00
Page 421
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
174 botol 124,355.00 - - - - 2 2 2 248,710.00
0,2 %
175 Phaproxin 500 mg tablet 880.00 200 - 200 200 - - - -
176 tablet 302.00 - - - - - - - -
mg
177 Pirantel pamoat 125 mg tab tablet 322.00 - - - - - - - -
178 Pirantel Pamoat susp 125 mg/5 ml bottle 10,100.00 - - - - - - - -
179 Pirantel Pamoat syrup botol 10,778.00 - - - - - - - -
180 Tablet 124.00 650 - 650 300 350 - - - -
(HCl)
181 tablet 129.00 100 - 100 - 100 - - - -
(HCl)
182 Prednison tablet 5 mg tablet 76.00 1,528 - 1,528 - 1,528 1,000 1,000 1,000 76,000.00
183 Prednison tablet/kapsul/kaplet 5 mg tablet 71.00 1,500 - 1,500 200 1,300 - - - -
184 Pularex Attapulgit tab 630 mg tablet 142.00 - - - - - - - -
185 Pyridol Syrup 60 ml botol 18,150.00 36 48 84 84 - - - -
186 Ranitidin 150 mg Tablet tablet 660.00 1,480 800 2,280 180 2,100 1,000 800 800 528,000.00
187 Ranitidin 50 mg/2 ml inj ampul 1,531.00 12 - 12 73 12 - - - -
189 Retinol/ Vit A 100.000 UI capsule 304.00 - - - - - - - -
190 Retinol/ Vit A 200.000 UI capsule 543.99 - - - - - - - -
191 Ringer Laktat 500 ml botol 7,630.00 30 - 30 - 30 - - - -
192 Roeko Endo Frost 200 ml botol 352,000.00 1 2 3 3 2 2 2 704,000.00
193 Salbutamol sulfate/salbutamol tab/kaps/kapl 2 mg tablet 63.00 1,790 100 1,890 1,890 - - - -
194 Salbutamol 2 mg tab tablet 67.00 - - - - - - - -
195 Salbutamol tablet/kapsul/kaplet 4 mg (sebagai Sulfat) tablet 80.00 - - - - 500 500 500 40,000.00
196 Salbutamol sulfate/salbutamol tab/kap/kapl 4 mg tablet 74.00 1,790 - 1,790 - 1,790 - - - -
197 Salbutamol sulfate/ Salbutamol sir 2 mg/5 Ml botol 4,446.00 23 - 23 - 23 - - - -
198 pot 2,654.00 - - - - - - - -
endap 4%
199 Sefadroksil kapsul 500 mg Kapsul 1,210.00 - - - - - - - -
200 Seftriakson serb inj 1.000 mg vial 4,998.00 - - - - - - - -
201 Setrizin sirup 5 mg/5 ml bottle 2,907.00 68 - 68 - 68 - - - -
Tablet
202 Simvastatin tab/kapl/salut selaput 10 mg Salut 110.00 1,390 - 1,390 170 1,220 - - - -
Selaput
203 Simvastatin tablet 10 mg Tablet 117.00 20 - 20 200 20 1,020 1,020 1,020 119,340.00
tablet
selaput
Page 422
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
205 Stesolid 5 mg/ 2,5 ml tube 13,202.00 - - - - - - - -
206 Stesolid 10 mg/2,5 ml tube 19,193.00 - - - - - - - -
207 Tetrasiklin tablet/kapsul/kaplet 500 mg kapsul 319.00 400 - 400 340 60 - - - -
208 tablet 84.00 1,639 - 1,639 194 1,445 - - - -
(HCL/Nitrat)
209 Tiamin (Vitamin B1) tablet 50 mg tablet 86.00 - - - - - - - -
tablet
210 salut 93.00 1,670 - 1,670 1,670 - - - -
selaput
211 Vapril 25 mg tablet 193.00 - - - - - - - -
212 box 6,550.00 - - - - - - - - -
mcg/kapsul)
213 Vitamin B Kompleks tablet 123.00 2,970 3,000 5,970 1,276 4,694 2,000 1,200 1,200 147,600.00
215 Vitamin B12 tablet 50 mcg tablet 52.00 2,630 2,000 4,630 4,630 1,500 1,500 1,500 78,000.00
216 Vitamin B12 tablet 50 mcg tablet 50.00 - - - - - - - -
217 Vitamin B6 10 mg tablet 138.00 - - - - - - - -
218 9,646.00 - - - - - - - -
plabot Plastik
219 Zink Sulfat/ Zink Sir 20 mg/5ml botol 3,122.00 - - - - - - - - - -
OBAT GIZI (DAK 2019) - - - - -
220 Ferro Fumarat 60 mg+ as Folat 0,4 mg Tablet 372.00 5,150 - 5,150 - 5,150 - - - -
221 Hemafort tablet 834.90 - - - - 2,000 2,000 2,000 1,669,800.00
222 sulfate, magnesium chloride anhydrous, potassium sachet 3,116.00 40 - 40 40 - - - -
223 Retinol (Vit A) Kapsul Lunak 100.000 IU Kapsul 324.00 25 - 25 25 - - - -
224 Kapsul 581.00 369 - 369 369 - - - -
IU
BAHAN MEDIS HABIS PAKAI (DAK ) - - - - - - -
225 Allkohol 70% bottle 28,733.33 3 - 3 - 3 - - - -
226 Alkohol 70% 1L botol 28,750.00 - - - - - - - - -
227 Arm sling L buah 17,424.00 - - - - - - - -
228 Arm sling M buah 17,424.00 - - - - - - - -
229 Arm sling S buah 17,424.00 - - - - - - - -
230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 - - - - - - - -
231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 9 - 9 9 - - - -
Page 423
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
232 Aximed Syringe 1 cc Dus 103,750.00 500 - 500 3 497 - - - -
233 Aximed Syringe 3 cc Dus 103,125.00 100 - 100 3 97 - - - -
234 Blood Lancet box 16,022.60 1 1 2 2 - 3 2 2 32,045.20
235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - - - - - - -
236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - - - - - -
238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - - - - - - -
241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 14 - 14 14 12 12 12 496,380.00
242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - - - - - - - -
243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - - - - - -
244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 5 - 5 5 - 24 12 12 496,380.00
245 Catgut Plain 3/0 DS 19 mm Sachet 40,137.40 - - - - - - - -
246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - - - - - - -
247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 - - - - - - - -
251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - - - - -
252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - - - - -
253 Chirurgic Gloves, size 8 pcs 9,525.12 - - - - - - - -
254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - - - - - -
255 Dermafix T 10x12cm pcs 6,939.90 5 - 5 5 - - - -
256 Examination Gloves size L box 58,564.00 - - - - 5 5 5 292,820.00
257 Examination Gloves size M box 58,564.00 - - - - - - - -
258 Examination Gloves size S box 58,564.00 - - - - - - - -
259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - - - - - -
260 Folley catheter 2 way no. 16 pcs 8,800.00 - - - - - - - -
261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - - - - -
Page 424
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - - - -
265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - - - -
266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - - - -
267 Hb Sahli set 96,800.00 - - - - - - - -
268 Hidrogen Peroxide 3% botol 3,864.00 - - - - - - - -
269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - - - - -
270 Infuset pcs 6,166.16 - - - - - - - -
271 IV- Cath WP, with wings & port no 20 pcs 8,165.08 - - - - - - - -
275 Kapas pembalut 250 gr roll 13,733.33 - - - - - - - -
276 Kapas pembalut 250 gr roll 13,750.00 - - - - - - - -
277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - - - - - - - -
278 Kasa kompres steril 40 x 40 pcs 1,760.00 13 - 13 13 - - - -
279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 4 - 4 4 - - - -
280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - - - - -
281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 20 - 20 20 - - - -
282 Lysol 1 liter botol 47,150.00 5 5 10 10 - - - -
283 Masker Ear Loop Box 20,202.00 - - - - - - - -
284 Masker Tie on Box 19,869.00 - - - - - - - -
285 Nasal Oksigen, O2 Cannula Size L pcs 8,385.30 - - - - - - - -
286 Nasal Oksigen, O2 Cannula Size M pcs 8,385.30 - - - - - - - -
287 Nasal Oksigen, O2 Cannula Size S pcs 8,385.30 - - - - - - - -
288 Nasal Oksigen, O2 Cannula Size XS pcs 8,385.30 - - - - - - - -
289 Onemed Alcohol Swab botol 11,000.00 - - - - - - - -
290 Onemed Blood Lancet box 16,022.60 - - - - - - - -
291 Onesept 500 ml botol 30,360.00 - - - - - - - -
292 Oxyflow Nasal Oxygen Dewasa piece 6,033.33 - - - - - - - -
293 Pharmaplast Cannofix-PU 6 CM X 8 CM pcs 6,850.00 - - - - - - - -
Page 425
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
294 Policrepe Pembalut Elastis 10 cm x 4,55 m Roll 34,572.00 - - - - - - - -
295 Safeglove Examination Gloves L box 39,182.00 - - - - - - - -
296 Sarung tangan obgyn steril(obgyn glove) pasang 21,285.00 - - - - - - - -
297 Silk Black 2/0 DS 19 MM Sachet 25,185.00 13 - 13 13 24 12 12 302,220.00
298 Silk Black 2/0 HR 20 mm Sachet 20,900.00 - - - - - - - -
299 Silk Black 3/0 DS 19 mm Sachet 24,405.00 - - - - - - - -
300 Stera Infuset anak pcs 3,850.00 15 - 15 - 15 - - - -
301 Surgical Mask Earloop box 18,150.00 - - - - - - - -
302 Surgical Mask Tie On box 18,150.00 - - - - - - - -
303 Swab 2 ply dus 14,040.84 - - - - - - - -
304 Syringe 10 cc dus 167,266.70 - - - - - - - -
305 Syringe 1cc pcs 1,045.80 - - - - - - - -
306 Syringe 1cc dus 106,523.56 - - - - - - - -
307 Syringe 3cc dus 107,421.38 - - - - - - - -
308 Syringe 5cc dus 119,090.61 - - - - - - - -
309 T-Chromic Catgut Chromic 2-0, 90 cm Tapercut pcs 67,980.00 - - - - - - - -
310 T-Chromic Catgut Chromic 3-0, 76 cm Reverse Cutting pcs 64,570.00 - - - - - - - -
311 TP. Disposable Syringe 3 cc pcs 750.39 - - - - - - - -
312 Tp. Disposable Syringe 5 cc pcs 892.78 - - - - - - - -

313 pcs 7,072.50 - - - - - - - -
Airvent, Luer Lock
314 T-Plain Catgut Plain 2-0, 90 cm Round Bodied pcs 56,210.00 - - - - - - - -
315 T-Plain Catgut Plain 3-0, 76 cm Reverse Cutting pcs 62,590.00 - - - - - - - -
316 T-Silk Silk/Sutera 2-0, 76 cm Reverse Cutting pcs 40,810.00 - - - - - - - -
317 T-Silk Silk/Sutera 3-0, 76 cm Reverse Cutting pcs 45,540.00 - - - - - - - -
318 Urine bag steril (t-valve) pcs 3,300.00 - - - - - - - -
PEMERIKSAAN HIV - - - - - - -
319 HIV Device Box 707,143.00 - - - - 14 14 14 9,900,002.00
BELANJA OBAT DAN BMHP PENGOBATAN GRATIS - - - - -
320 Cut gat chromic 3/0 +jarum 1 1/2 GT 35 mm pcs 6,142.00 - - - - - - - -
SUMBER DANA APBD I - - - - - - -
VAKSIN - - - - - - -
Page 426
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
321 BCG +Pelarut BCG Vial 61,996.00 - - - - - - - -
322 Campak + Pelarut Campak Vial 28,204.00 - - - - - - - -
323 DPT-HB-Hib Vial 78,991.00 - - - - - - - -
324 DT Vial 17,996.00 - - - - - - - -
325 Hepatits B Buah 23,991.00 - - - - - - - -
326 IPV Vial 139,760.00 - - - - - - - -
327 IPV Vial 144,540.00 - - - - - - - -
328 MR Vial 141,648.00 - - - - - - - -
329 Polio+ Dropper Polio Vial 19,954.00 - - - - - - - -
330 Td Vial 16,995.00 - - - - - - - -
ANTI RABIES - - - - - - -
331 VAR (Vaksin Anti Rabies)/ Verorab Vial 165,000.00 - - - - - - - -
OBAT FILARIASIS - - - - - - -
332 Albendazol 400 mg tablet 258.74 7,800 - 7,800 200 7,600 - - - -
OBAT GIZI - - - - - - -
333 Tablet Tambah Darah (Rematri) tablet 372.00 - - 16,800 16,800 - - - - -
334 Vitamin 100.000 IU (Biru) kapsul 310.00 - - - - - - - - -
335 Vitamin A 200.000 IU (Merah) kapsul 519.20 - - - - - - - - -
OBAT MALARIA - - - - -
336 Blood Slide Kotak 18,509.00 2 - 2 - 2 5 5 5 92,545.00
337 DHP Frimal tablet 3,498.00 - - - - - - -
338 Kelambu GF Buah 61,077.00 - - - - - - -
339 Primaquin 15 mg tablet 235.00 - - - - - - -
OBAT KIA IBU - - - - -
340 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - - - - -
341 Ca. Glukonas Injeksi ampul 10,351.00 - - - - - - - -
342 Euthyrox 50 mcg tablet 735.00 - - - - - - - -
343 Gentamicin injeksi 40 mg/ml ampul 3,685.00 - - - - - - - -
344 Methylergometrin Injeksi ampul 3,102.00 10 - 10 - 10 - - - -
345 MgSO4 20 % fls 3,328.00 12 - 12 12 - - - -
346 MgSO4 40 % fls 3,796.00 12 - 12 12 - - - -
OBAT KIA ANAK - - - - -
347 Ampicillin inj 1000 mg/ml Vial 8,649.00 - - - - 10 10 10 86,490.00
Page 427
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
348 Gentamisin 40 mg/ ml inj Tube 3,685.00 - - - - 10 10 10 36,850.00
349 Oksitetrasiklin 1% Salep Mata Tube 2,600.00 25 25 50 25 25 25 25 25 65,000.00
OBAT TB PARU - - - - -
350 Box Slide Kotak 41,342.00 - - - - - - - -
351 Kaca Slide Kotak 30,000.00 2 - 2 2 - - - -
352 Kaca Slide Kotak 20,747.00 - - - - - - - -
353 OAT Kategori Anak Paket 232,518.00 - - - - - - - -
354 OAT Kategori I Paket 377,900.00 1 - 5 1 4 - - - -
355 OAT Kategori II Paket 1,259,990.00 - - - - - - - -
356 Pot Sputum Pot 2,500.00 196 - 196 196 - - - -
357 Reagen Ziehl Neelsen Kit 276,000.00 - 13 13 13 - - - -
358 Sputum Pot Buah 2,950.00 1,000 1,000 2,000 - 60 - - - -
359 Tuberkulin Vial 625,900.00 - - - - - - - -
KUSTA - - - - -
360 MDT PB Dewasa Blister 12,569.00 - - - - - - - -
ALAT DETEKSI RESIKO KEHAMILAN - - - - - - -
361 Paket ADRK II Paket 422,980.00 - - - - - - - -
IMUNISASI - - - - - - -
362 ADS 0,05 ml Buah 1,518.00 - - - - - - - -
363 ADS 0,5 (Oneject) Buah 1,621.00 - - - - - - - -
364 ADS 0,5 ml Buah 1,127.00 - - - - - - - -
365 ADS 0,5 ml Buah 1,090.00 - - - - - - - -
366 Ads 0,5 ml (Skifa) Buah 1,240.00 - - - - - - - -
367 ADS 0,5 ml SKIFA buah 1,240.00 - - - - - - - -
368 Ads 0,5 ml Solosot Mini Kotak 165,550.00 - - - - - - - -
369 ADS 5 ml buah 1,705.00 - - - - - - - -
370 ADS 5 ml Buah 1,705.00 - - - - - - - -
371 ADS 5 ml Buah 1,439.00 - - - - - - - -
372 ADS 5 ml Buah 1,500.00 - - - - - - - -
373 RCW Unit 2,266,454.00 - - - - - - - -
374 Safety Box pcs 16,608.00 - - - - - - - -
Page 428
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
375 Safety Box 2,5 ml Buah 12,500.00 - - - - - - - -
376 Safety Box 5 ml Buah 20,394.00 - - - - - - - -
377 Vaccine Carrier buah 1,870,000.00 - - - - - - - -
OBAT FLU BURUNG - - - - - - -
378 Oseltamivir kapsul 12,969.00 - - - - - - - -
OBAT DIARE - - - - - - -
379 Garam Oralit Sachet 257.00 - - - - - - - -
380 Garam Oralit Sachet 253.00 157 - 157 - 157 - - - -
381 Zink Tablet tablet 551.00 500 - 500 300 200 200 200 200 110,200.00
OBAT HIV/AIDS - - - - - - -
382 Rapid 1 : SD HIV test 11,975.00 219 - 219 219 - - - -
383 Rapid 2 : Focus Diagnostic test 13,615.00 - - - - - - - -
384 Rapid Sifilis Ab test 20,400.00 113 - 113 113 - - - -
385 RPR Sifilis test 4,250.00 - - - - - - - -
OBAT HEPATITIS - - - - - - -
386 HB Imuno Globulin Kotak 1,325,000.00 - - - - - - - -
387 Rapid Test SD Bioline HBsAg test 9,870.00 - - - - - - - -
Reagensia/ Alat - - - - - - -
388 Rapid 1 HIV (SD Bioline HIV 1/2) test 11,975.00 - - - - - - - -
389 Rapid 2 HIV (Focus) test 13,615.00 - - - - - - - -
390 Rapid 2 HIV (KHB) test 12,500.00 - - - - - - - -
391 Rapid 3 Diagnostar test 13,771.00 - - - - - - - -
392 Rapid 3 HIV Test (Vikia) test 19,480.00 - - - - - - - -
393 Rapid Sifilis Trepocheck test 9,697.00 - - - - 50 50 50 484,850.00
394 RPR Sifilis test 4,250.00 - - - - - - - -
SUMBER DANA APBD II - - - - - - -
OBAT KATARAK - - - - - - -
395 Infusion set dewasa (20 drops/ml) buah 4,064.00 - - - - - - - -
396 Kasa hydrophil 40 x 80 cm roll 133,350.00 - - - - - - - -
OBAT PROGRAM - - - - - - -
397 L- Zinc botol 31,350.00 - - - - - - - -
398 Lagesil Suspensi botol 40,755.00 - - - - - - - - -
REAGENTIA - - - - - - -
399 Objek Gelas Kotak 50,000.00 - 5 5 5 - - - -
Page 429
JUMLAH PEMBERIAN
NO NAMA OBAT SATUAN
TOTAL
JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18
400 Reagentia Eosin 1% (1 Liter) Liter 1,837,000.00 - - - - - - - -
REAGENSIA - - - - - - -
401 Larutan Alkohol 96% botol 242,000.00 - - - - - - - -
402 Larutan Metanol botol 665,500.00 - - - - - - - -
403 Reagen Benedict botol 484,000.00 - - - - - - - -
404 Reagen Natrium Sitrat botol 514,250.00 - - - - - - - -
405 Reagen Receker botol 2,238,500.00 - - - - - - - -
406 Reagensia Asam Asetat botol 544,500.00 - - - - - - - -
407 Slide test widal Unit 302,500.00 - - - - - - - -
BELANJA STICK NARKOBA - - - - - - -
408 Multi 3 in 1 (AMP/THC/MOP) Box 2,632,000.00 - - - - - - - -
409 Multi Drug 3 Panel (AMP. MOP. THC) Box 2,632,000.00 - - - - - - - -
PENINGKATAN KESEHATAN MASYARAKAT - - - - - - -
410 Stick Pemeriksaan Asam Urat Box 231,200.00 - - - - - - - -
411 Stick Pemeriksaan Gula Darah Box 231,200.00 - - - - - - - -

Alkohol 300 ml Botol 4 4 4 - - - -
Alkohol 1 L Botol 2 2 2 - - - -
Hand Sanitizer Botol 3 3 3 - - - -
DHP-Frimal Tablet 2,134.00 9 9 9 19,206.00
Fokus Diagnostis Syphilis Test 13,900.00 50 50 50 695,000.00
Fokus New HIV 1/2 Test 250 250 250 -
One Med Povidone Iodine 30 ml botol 3,679,995.00 10 10 10 36,799,950.00
TOTAL 63,071,309

dr.Hj.Saodah Nasution Surya Doni, S.Farm,.Apt Sury Astika S.Farm,Apt Nensy Amrisyah Situmorang,SKM Rehyani Bangun
NIP.19620405 198911 2 001 NIP.19810620 200904 1 005 Nip. 19830312 201001 2 016 19810119 200701 2 008 Nip. 19820505 200801 2 003
Page 430
-
-
1,000
-
-
-
-
-
-
-
-
-
-
-
1,000
-
-
4,000
-
Page 431
100
-
-
-
-
-
-
-
-
24
-
-
-
-
-
-
-
300
-
-
Page 432
-
-
-
480
-
500
-
-
-
-
-
1,000
-
-
-
-
-
-
-
-
-
-
-
-
Page 433
-
-
-
-
-
-
-
-
-
200
-
-
-
-
-
24
-
50
1,500
-
700
-
Page 434
-
300
-
-
-
500
-
-
-
-
-
-
-
-
-
-
-
-
900
50
-
-
500
-
500
500
-
-
-
Page 435
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
200
-
-
5,200
50
-
-
-
1,000
1,000
-
-
Page 436
-
-
-
-
-
-
-
-
48
700
-
70
-
-
-
2
100
-
-
-
-
-
-
-
Page 437
-
-
-
3,000
100
2,000
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 438
-
-
100
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 439
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
5
-
-
-
-
-
-
-
-
-
-
-
Page 440
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 441
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 442
-
25
-
-
-
-
-
-
-
-
13
1,000
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 443
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
5
Page 444
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
4
2
3
-
-
-
-
-
Page 445

Lplpo TW 3 2020

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Lplpo TW 3 2020

Diunggah oleh

Hak Cipta:

Format Tersedia

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PUSKESMAS TAHUN 2020

Bahan Obat-obatan (DAK )

Acetyl cysteine/ N-Asetil sistein tablet/kaplet/kapsul

79 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml (0,1%) ampul 1,749.00 5 5 5 - -

94 gentamisin/gentamycin sulfate salep mata 0,3% (3mg/g) tube 2,810.00 - 4 4 - -

98 Griseofulvin (microninized) tablet/kapsul/kaplet 125 mg tablet 245.00 4,000 4,000 3,900 - -

114 Isosorbid Dinitrat/ Isosorbide dinitrate tab/kaplet 5 mg tablet 89.00 - - - - -

140 Methylprednisolone tablet 4 mg tablet 528.66 - - - - - -

225 Allkohol 70% bottle 28,733.33 5 - 5 4 3 - -

226 Alkohol 70% 1L botol 28,750.00 - - - - 3 3 3 86,250

227 Arm sling L buah 17,424.00 - - - - - -

228 Arm sling M buah 17,424.00 - - - - - -

229 Arm sling S buah 17,424.00 - - - - - -

230 Aseptic gel 500 cc+ dispenser bottle 25,300.00 21 - 21 11 10 - -

231 Aximed Non woven fixation 5 cm x 10 m roll 54,812.50 - - - - - -

232 Aximed Syringe 1 cc Dus 103,750.00 20 - 20 - - -

233 Aximed Syringe 3 cc Dus 103,125.00 266 2 268 1 208 2 2 2 206,250

234 Blood Lancet box 16,022.60 - - - - - -

235 Catgut Chromic 2/0 DS 30 mm Sachet 42,665.00 - - - - - -

236 Catgut chromic 2/0 HR 30 mm Sachet 34,770.00 - - - - - -

237 Catgut chromic 2/0 HR 30 mm Sachet 33,873.38 - - - - - -

238 Catgut Chromic 3/0 DS 30 mm Sachet 42,665.00 - - - - - -

239 Catgut chromic 3/0 HR 30 mm Sachet 34,770.00 - - - - - -

240 Catgut chromic 3/0 HR 30 mm Sachet 33,873.38 - - - - - -

241 Catgut Plain 2/0 DS 19 mm Sachet 41,365.00 - - - - - -

242 Catgut Plain 2/0 DS 19 mm Sachet 40,137.40 - - - - - -

243 Catgut Plain 2/0 HR 20 mm Sachet 36,340.00 - - - - - -

244 Catgut Plain 3/0 DS 19 mm Sachet 41,365.00 - - - - - -

245 Catgut Plain 3/0 DS 19 mm Sachet 40,137.40 - - - - - -

246 Catgut Plain 3/0 HR 20 mm Sachet 36,340.00 - - - - - -

247 Catheter Tro-Venocath, Sine 20 G pcs 12,631.00 6 - 6 - - -

249 Catheter Tro-Venocath, Sine 24 G pcs 12,631.00 - - - - - -

250 Catheter Tro-Venocath, Sine 26 G pcs 23,843.00 - - - - - -

251 Chirurgic Gloves, size 7 pcs 9,525.12 - - - - - -

252 Chirurgic Gloves, size 7,5 pcs 9,525.12 - - - - - -

253 Chirurgic Gloves, size 8 pcs 9,525.12 - - - - - -

254 Cuticell Classic 10 cm x 10 cm piece 5,198.00 - - - - - -

255 Dermafix T 10x12cm pcs 6,939.90 - - - - - -

256 Examination Gloves size L box 58,564.00 - - - - - -

257 Examination Gloves size M box 58,564.00 2 2 4 3 3 3 3 175,692

258 Examination Gloves size S box 58,564.00 - - - - - -

259 Fixomull Stretch 5 cm x 5 m roll 37,440.00 - - - 10 - -

260 Folley catheter 2 way no. 16 pcs 8,800.00 - 5 5 5 - -

261 Germany Tro-Sensosurge Steril Glove 8.0 pasang 7,254.00 - - - - - -

262 Germany Tro-Sensosurge Steril Glove 7.5 pasang 7,254.00 - - - - - -

263 Germany Tro-Sensosurge Steril Glove 7.0 pasang 7,254.00 - - - - - -

264 Gynaecologycal Glove, Large pcs 40,733.00 - - - - - -

265 Gynaecologycal Glove, Medium pcs 40,733.00 - - - - - -

266 Gynaecologycal Glove, Small pcs 40,733.00 - - - - - -

267 Hb Sahli set 96,800.00 - - - - - -

268 Hidrogen Peroxide 3% botol 3,864.00 - - - - - -

269 Hydrex Surgical Scrub 500 ml Botol 98,616.00 - - - - - -

270 Infuset pcs 6,166.16 - 20 20 40 - -

275 Kapas pembalut 250 gr roll 13,733.33 6 - 6 6 - -

276 Kapas pembalut 250 gr roll 13,750.00 - 5 5 5 - -

277 Kasa hydrophil Steril Uk. 18x22 box 8,240.00 - 5 5 5 30 - -

279 Kasa pembalut hydrohil 4 m x 10 cm roll 1,650.00 - - - - - -

280 Kasa Pembalut Hydrophil 4m x 15cm roll 2,310.00 - - - - - -

281 Kasa Steril 10 x 10 cm, 8 ply 1x5's Dus 8,122.40 - - - - - -

282 Lysol 1 liter botol 47,150.00 3 - 3 3 5 - -

283 Masker Ear Loop Box 20,202.00 - - - - - -

284 Masker Tie on Box 19,869.00 6 - 6 - 30 - -