BERITA ACARA SERAH TERIMA PENGELOLAAN OBAT

ANTARA APOTEK SAKINAH 74 DENGAN RS MOEDJITO

Pada hari ini ………… Tanggal …… Bulan ………………………… Tahun …………, sesuai
dengan Keputusan Menteri Kesehatan Nomor. 1332/MENKES/SK/X/2002, tentang Ketentuan
dan Tata Cara Pemberian Izin Apotek, kami yang bertanda tangan dibawah ini :
1. Pemilik Apotek :
Nama : :
Alamat :
Nama Apotek :
Alamat Apotek :

2. Dengan disaksikan oleh :

Nama :
NIP :
Pangkat :
Jabatan :

Nama :
NIP :
Pangkat :
Jabatan :
Telah melakukan penyerahan pengelolaan obat sebagaimana tersebut dalam lampiran ini,
Dikarenakan Apotik Sakinah 74 sudah tidak beroperasional
Kepada :
Nama APA :
Nomor SIPA :
Alamat :
Nama Sarana :
Alamat :
Berita Acara ini kami buat sesungguhnya dengan penuh tanggung jawab.
Berita acara ini dibuat dalam rangkap 4 (empat) dan dikirimkan kepada :
1. Kepala Dinas Kesehatan Provinsi Jawa Timur
2. Kepala Balai Besar POM di Surabaya
3. Kepala Dinas Kesehatan Kabupaten Jombang
4. Arsip
Jombang,
Yang Membuat Berita Acara
Pemilik Apotek

dr.Wartik
Saksi-saksi :
1.
2.
3.
4.
 LAMPIRAN BERITA ACARA SERAH TERIMA PENGELOLAAN OBAT
ANTARA APOTEK SAKINAH 74 DENGAN RS MOEDJITO

No. Nama Obat Satuan Jumlah Kadaluwarsa No. batch

1. Yusimox dry syrup Botol 18 5/23 02031
2. Maaggel suspensi Botol 9 12/22 52455375
3. Domperidone sirup generik Botol 8 12/24 S.2319091
4. Ambroxol sirup generik Botol 13 11/22 2011-12-184
5. Antasida doen suspensi Botol 14 01/23 S 01012 BA
6. Cefadroxil sirup kering Botol 5 08/22 DS 08003 BK
7. Zinc syrup Botol 5 11/22 S 11004 BK
8. Erysanbe dry sirup Botol 2 07/23 WG9062
9. Vesperum drops Botol 1 08/21 90208
10. Vosea Botol 3 06/23 QF011G
11. Lerzin Botol 10 10/24 00830
12. Cazetin drops Botol 3 11/22 00332
13. Paracetamol sirup generik Botol 13 04/22 64004002
14. Zinc Tablet 197 12/23 20ZC10466
15. Erlamycetin salep mata Tube 2 10/24 00455071
16. Oxytetracycline salep mata Tube 5 04/22 D90484W
17. Genoint salep mata Tube 6 09/22 1655024
18. Genoint tetes mata Botol 5 04/23 00855011
19. Cendo Catarlent Botol 2 05/22 OCA0513
20. Reco tetes mata Botol 8 05/22 0091120003
21. Erlamycetin tetes telinga Botol 3 11/23 D0655188
22. Reco tetes telinga Botol 3 09/23 0100920005
23. Genoint salep kulit Tube 2 11/22 017551159
24. Nisagon cream Tube 17 12/22 02031
25. Ketoconazole Tube 22 11/22 0K02
26. Betametason Tube 26 12/23 36455017
27. Hydrocortisone Tube 29 11/22 KL3002
28. Gentamycin Tube 4 12/22 L82473T
29. Acyclovir Tube 30 10/24 36305050
30. Miconazole Tube 23 02/24 B00242W
31. Acyclovir 400mg Tablet 244 11/23 26304081
32. Akita Tablet 202 11/22 00131
33. Alleron Tablet 301 10/25 0110057
34. Allopurinol 100mg Tablet 378 12/22 T12046BK
35. Allopurinol 300mg Tablet 108 09/22 HTAL0B05258
36. Alofar 100 Tablet 94 08/22 01528
37. Alofar 300 Tablet 148 07/22 00827
38. Alpara Tablet 135 03/23 A060M026
39. Alvita Tablet 282 11/22 11005
40. Ambroxol Tablet 365 10/22 09619J0050
41. Aminophylline Tablet 126 11/23 KOA014
42. Amlodipine 10mg Tablet 88 09/22 1762010010
43. Amlodipine 5mg Tablet 500 10/22 T10039BK
44. Amoxicillin Tablet 530 12/22 2012-34-115
45. Ampicillin Tablet 57 09/24 200925116
46. Anastan Forte Tablet 150 01/24 K000021
47. Antalgin Tablet 95 02/24 00201010
48. Antasida doen Tablet 266 02/22 T02083BK
49. Asam Mefenamat Tablet 274 11/22 05320K0120
50. Aspilet Tablet 61 09/22 20053901
51. Beneuron Tablet 317 09/23 TSK65849
52. Berlosid Tablet 29 09/22 IRB051135
53. Bisoprolol Tablet 154 06/23 HTBSPC03094
54. Brocon Tablet 118 07/22 00827
55. Bronex Tablet 180 04/24 04001
56. Calcifar Tablet 66 12/21 90112
57. Calcium lactate Tablet 60 07/23 A01298
58. Calortusin Tablet 174 11/22 T11034BK
59. Captopril12,5mg Tablet 215 05/24 51E0386
60. Captopril 25mg Tablet 174 06/24 FL1044
61. Captopril 50mg Tablet 10 03/23 20CA3002
62. Carbidu 0,5mg Tablet 279 11/22 IK1051
63. Carbidu 0,75mg Tablet 194 10/22 IJ1941
64. Caviplex Tablet 146 12/23 F1455499
65. Cefadroxil Tablet 79 07/23 20G0664
66. Cetirizine Tablet 309 12/22 80012001
67. Cimetidine Tablet 203 09/22 00129
68. Ciprofloxacin Tablet 440 12/22 2012-09-108
69. Clindamycin 150mg Tablet 30 12/23 264370044
70. Clindamycin 300mg Tablet 3 - -
71. Clopidogrel Tablet 20 07/21 H92048B
72. Colpica Tablet 151 01/23 TA0341
73. Coparcetin Tablet 20 02/22 IB2451
74. Coric Tablet 60 05/22 503
75. Cotrimoxazole Tablet 74 06/23 200602123
76. CTM loss Tablet 411 09/22 K20081
77. Demacolin Tablet 192 10/24 KOA006
78. Dexametason 0,5mg loss Tablet 165 11/22 22202011
79. Dexaharsen 0,5mg Tablet 20 05/24 0083104
80. Dexaharsen 0,75mg Tablet 160 06/24 0085109
81. Dexanta Tablet 410 05/24 51G4148
82. Yusimox Tablet 66 07/23 03926
83. Dextral Tablet 174 06/22 D03CU140
84. Diclofenac sodium Tablet 124 09/22 36365054
85. Digoxin 0,25 Tablet 124 04/22 A8613DX
86. Dimenhidrinat Tablet 154 05/25 T3720006
87. Dionicol Tablet 57 05/22 02425
88. Dolo licobion Tablet 192 03/22 CRB059017
89. Domperidone Tablet 371 11/24 T3620054
90. Dulcolax Suppo 29 12/23 19121528
91. Eltazon Tablet 182 07/22 00927
92. Erphaflam Tablet 108 01/24 C2520406
93. Eryra forte Tablet 11 06/21 T06083AJ
94. Erysanbe Tablet 31 03/22 AC2775
95. Fargoxin Tablet 42 01/24 LA2611
96. Farmalat Tablet 7 - -
97. Farmoten 25mg Tablet 60 06/22 LF2091
98. Farsifen 200mg Tablet 42 07/22 00727
99. Farsifen 400mg Tablet 102 10/22 01330
100. Fasidol Tablet 12 09/24 00429
101. Fasorbid Tablet 84 03/21 MC2861
102. Fenamin Tablet 167 09/24 09015B
103. FG Troches Tablet 9 05/21 19453
104. Folic Tablet 24 08/21 602HH
105. Formyco 200mg Tablet 11 02/22 AB2557
106. Furosemide Tablet 68 08/25 038103
107. Gasela Tablet 158 10/22 C0455220
108. Wiros Tablet 80 09/24 009076
109. Glibenclamide Tablet 447 01/26 095104
110. Glimepiride 1mg Tablet 194 04/23 51E0606
111. Glimepiride 2mg Tablet 162 09/22 51J4126
112. Glimepiride 3mg Tablet 100 05/23 51E0609
113. Glimepiride 4mg Tablet 91 09/23 51J0322
114. Glucodex 80mg Tablet 50 10/22 51K4166
115. Glucosamine Tablet 160 05/25 01358
116. GOM 10ml Tablet 20 01/24 L18004
117. Grafadon Tablet 284 10/22 0J018G
118. Grafalin 2mg Tablet 97 06/24 QF105G
119. Grafallin 4mg Tablet 70 06/24 QF086G
120. Grafazol Tablet 146 09/24 ZI310G
121. Gralixa Tablet 63 04/24 ZD128C
122. Grantusif Tablet 146 03/24 QC056G
123. Grathazon 0,5 Tablet 15 09/24 QI370
124. Gravask 10mg Tablet 38 06/22 QF228G
125. Gricin 125mg Tablet 34 - -
126. Griseofulvin Tablet 45 04/22 DY7A055
127. Guaifenesin Tablet 158 08/21 H9035
128. Histigo Tablet 130 10/22 00330
129. Hufabion Tablet 100 11/21 LI100619
130. Hufagripp forte Tablet 100 11/22 L101010
131. Etamox Tablet 142 11/23 KL4054
132. Hufralgin Tablet 10 09/21 M200709
133. Ibuprofen Tablet 317 10/22 2010-22-134
134. Icobal Tablet 2 - -
135. Inamid Tablet 181 07/22 0040021-2
136. Incidal OD Tablet 8 02/23 X2513104
137. Kaditic Tablet 4 - -
138. Kalzana Tablet 10 11/21 L2749
139. Lansoprazole Tablet 24 11/22 0178076
140. Latibet Tablet 124 09/22 01129
141. Laxana Tablet 102 09/24 00329
142. Lerzin caps Tablet 50 10/24 01430
143. Lexacrol Tablet 80 07/25 LIICL040R
144. Likokalk plus Tablet 59 05/25 GRB056004
145. Lodecon forte Tablet 93 11/22 TRW31
146. Lodecon Tablet 305 10/25 TOW5
147. Lokev Tablet 88 11/24 00131
148. Loperamide Tablet 136 09/22 2009-01-328
149. Loratadine Tablet 97 05/25 10220E0020
150. Meloxicam 15mg Tablet 18 - -
151. Meloxicam 7,5mg Tablet 94 05/23 20E0493
152. Metamizole Tablet 18 03/22 A90628
153. Metformin Tablet 330 11/22 120540
154. Methyl prednisolone 4mg Tablet 107 06/22 HTMPSD03120
155. Metronidazole Tablet 68 03/24 200314129
156. Molagit Tablet 88 08/24 MIICG033
157. Neurodex Tablet 69 02/22 51C4166
158. Nifedipine Tablet 104 01/24 5104133
159. Novagesic Tablet 38 12/22 2012-12-27
160. Novamox Tablet 127 01/23 210110112
161. Omegesic Tablet 330 10/24 1020145
162. Omeprazole Tablet 410 11/22 KL1023
163. Omeric 100 Tablet 8 05/24 051925
164. Omeric 300 Tablet 35 02/25 0220198
165. Ondansentron Tablet 14 04/22 2004034
166. Oralit Tablet 54 04/22 P04010BK
167. Orphen Tablet 171 09/24 TWW52
168. Parasetamol Tablet 537 12/23 21710012
169. Piracetam 1200mg Tablet 10 07/22 CPCMB0090
170. Piracetam 400mg Tablet 50 11/21 10119K0010
171. Piroxicam 10mg Tablet 120 07/25 039805
172. Plantacid forte Tablet 90 08/24 KTPTFA04068
173. Prednison loss Tablet 335 10/21 M9028
174. Primadex Tablet 13 11/22 3282152
175. Primadex forte Tablet 131 02/24 51B0412
176. Pronicy Tablet 30 01/22 TTPR0F01800
177. Propanolol 10mg Tablet 350 05/25 5160094
178. Propanolol 40mg Tablet 70 02/25 51C0392
179. Ranitidine Tablet 301 11/22 HTRNTB06504
180. Renabetic Tablet 152 10/22 LJ1231
181. Renadinac Tablet 230 09/22 LI0771
182. Roverton Tablet 134 08/24 00428
183. Salbutamol 2mg Tablet 217 10/23 A8217JX
184. Salbutamol 4mg Tablet 100 09/22 A8322IX
185. Samcofenac Tablet 435 10/23 11721LL
186. Samquinor Tablet 83 11/23 11310LMZ
187. Scopma Tablet 132 04/24 00823
188. Scopma plus Tablet 0 - -
189. Selvim 10mg Tablet 10 08/24 00623
190. Selvim 20mg Tablet 104 06/22 00626
191. Simvastatin 10mg Tablet 154 11/22 T11029BK
192. Simvastatin 20mg Tablet 105 01/22 HTSVNED1010
193. Soldextam Tablet 54 01/24 TAV10
194. Polofar 2mg Tablet 90 07/23 90406
195. Polofar plus Tablet 110 05/22 00523
196. Pondex forte Tablet 5 08/21 50J0093
197. Samconal Forte Tablet 83 09/22 107KK
198. Sulfadiazine Tablet 30 05/22 00625
199. Superhoid supp Suppo 12 07/23 G20054
200. Tera F Tablet 104 01/23 T01054BA
201. Tidifar Tablet 125 05/22 00925
202. Trianta Tablet 41 01/22 01021
203. Trodex Tablet 50 01/23 TA0581
204. Vesperum Tablet 177 10/24 00130
205. Vit C Loss Tablet 1018 09/23 GP1020159
206. Vit K Loss Tablet 74 09/24 5055008
207. Vit B1 Loss Tablet 460 02/24 00227002
208. Voltadex Tablet 286 06/22 51W4105
209. Vosea Tablet 220 11/24 QK175G
210. Winatin Tablet 157 07/24 00427

Jombang,
Yang Menerima Yang Menyerahkan

( ) ( )

Saksi-saksi :
1.
2.
3.
4.