BERITA ACARA SERAH TERIMA PERALIHAN TANGGUNG JAWAB

PELAYANAN KEFARMASIAN

Padahari ini SelasaTanggal 03Bulan08 tahun202l ,sesuai denganKeputusanMenteri

Kesehatan Nomor 9 tahun 20L7, tentang Ketentuan dan Tata Cara pemberian izin Apotik,
kami yang bertanda tangan dibawah ini:
A. Apoteker Pengelola Apotik Lama :
Nama apt. Drs. Stephanus Sugianto Setiawan.,
Nomor STRA t9 600926I STRA- U P/ 2 00 U r2B7 7
Nomor SIPA 02u 2.3s.1 I 3 1.73.08 l - 1.7 7 9 .3 I 2016
Alamat domisili Jl. Surya Bahagia II-A/51 RT 009 RW 05 Kedoya Utara,
Kebon leruk , Jakarta Barat, Jakarta.
Telepon | +62 816-1398-138
Nama Apotik : Apotek Erha21
AlamatApotik : Lippo Mall Puri, Lower Ground Unit 67-68, Jl. Puri Indah
Blok U1, Kembangan, Jakarta Barat

Nama apt. MG Niken Arumdati., S.Farm.,

Nomor STRA 993 0906/STRA-U S D I 2016 I 24s822
_1
Nomor SIPA
Alamat Domisili Jl. Sandang D5 RT 1 RW 11 Kelurahan Palmerah
Kecamatan Palmerah Jakafta Barat, Kota Jakafta Barat DKI
lakafta 11480
Telepon :081371202789 .

Nama : Yoan Kristin

Jabatan : Supervisor .

Telah melakukan penyerahan :

1. Resep - resep berjumlah 36500 lembar .
2. Telah melakukan pengalihan obat keras / obat bebas terbatas / obat bebas
. sebagaimana dalam daftar terlampir.
3. Kunci-kunci lemari penyimpanan terdiri dari 2 Buah.
4. Lain - lain yang dianggap perlu .

Realisasi dari serah terah terima dan pengalihan.tanggung jawab ini setelah SIPA APA
baru diterbitkan dari PTSP.

Demikianlah Berita Acara Serah terima ini kami buat sesungguhnya dengan penuh
tanggungjawab,
Yang Menerima, Yang Menyerahkan,
Apoteker Pengelola Apotik Baru Apoteker Pengelola Apotik Lama

apt. MG Niken Arumdati., S.Farm., apt. Drs. Stephanus Sugianto Setiawan.,

SIPA. srpA. 02t I 2.3s.1 I 3L.73.08 l -L.77 9.3 I 20t6

Saksi:

Yoan Kristin
Superuisor
 LAMPIRAN BERITA ACARA SERAH TERIMA PERALIHAN TANGGUNG JAWAB
PELAYANAN KEFARMASIAN

No Nama Produk BACTH EXPIRED Jumlah Satuan

NUMBER DATE
1 Aza 20 Cream 10 g RA0087 01/23 24.00 Tube
2 Aza 20 Gel 30 ml QK1652 11/22 45.00 Botol
3 Biogesic 19096001 05/24 3.00 Strip
4 Clidacor Capsule 300 mg RB0317 02/04 126.00 Capsule
5 Doxicor 100 mg QL2027 12/22 90.00 Capsule
6 Elopro Cream 10 g RC0724 03/24 6.00 Tube
7 Elopro Gel 10 g QK1760 11/23 7.00 Tube
8 Elopro Ointment 10 g QK1760 11/23 5.00 Tube
9 Eqinon Cream 15 g QH1180 08/23 5.00 Tube
10 Eqinon Forte Cream 15 g RA0216 01/23 34.00 Tube
11 Erazol Cream 15 g QE0774 05/22 2.00 Tube
12 ERHA AcneAct Acne Back Spray 60 ml QJ141 10/22 42.00 Botol
13 ERHA AcneAct Acne Pressed Powder 13 g QG1124 07/22 9.00 Case
14 ERHA AcneAct Acne Spot Gel 10 g RB0367 02/23 57.00 Tube
15 ERHA AcneAct Acne Sun Friendly 30 g EC0768 04/23 17.00 Tube
16 ERHA Acneact ACSBP 60 g RD0976 04/24 287.00 Tube
17 ERHA AcneAct BHA & Ceramide Gentle Acne Moisturizer 30 g RC0445 03/23 25.00 Tube
18 ERHA AcneAct Clarifying Toner 60 ml QJ1444 10/23 14.00 Botol
19 ERHA Acneact WH Acne Blemish Toner 100 ml QJ1583 10/23 10.00 Botol
20 ERHA Acneact WH Acne Calming Gel 100 g QL1948 12/22 9.00 Tube
21 ERHA Acneact WH Gentle Acne Facial Wash 100 g QJ1586 11/22 11.00 Tube
22 ERHA Acneact WH Pore Minimizing Toner 100 ml QK1778 11/22 10.00 Botol
23 ERHA Age Corrector Active Defense 15 ml RB0413 02/23 10.00 Botol
24 ERHA Age Corrector Essence 100 ml RB0412 02/23 12.00 Botol
25 ERHA Age Corrector Firming Eye Cream 15 g RA0151 01/23 36.00 Botol
26 ERHA Age Corrector Moisture Control 15 ml RB0412 02/23 14.00 Botol
27 ERHA Age Corrector Night Charge 15 ml QI1903 12/22 15.00 Botol
28 ERHA Age Corrector Serum 20 ml RB03701 02/23 66.00 Botol
29 ERHA Age Corrector Skin Renew 15 ml QL1904 12/22 13.00 Botol
30 Erha Brightening Home Peeling Solution 30 ml QG0985 07/22 4.00 Botol
31 Erha Hand Moisturizing Spray with BKC 50 ml QG1037 07/22 33.00 Botol
32 ERHA Hand Sanitizer Cream 30 g ARV 08/22 19.00 Tube
33 Erha Hand Sanitizer Gel 370 ml Q11260 09/22 16.00 Botol
34 Erha Luminous Pearl BB Cushion 01 - Beige ADV 04/22 8.00 Tube
35 Erha Luminous Pearl BB Cushion 01 - Ivory BFV 06/22 10.00 Tube
36 Erha Luminous Pearl BB Cushion 01 - Natural CJV 09/22 12.00 Tube
37 Erha Nutraceuticals Zincore Capsule 30's RC0640 03/23 58.00 Box
38 Erha Perfect Shield Helios 30 g RC0738 04/23 45.00 Tube
39 ERHA Perfect Shield Sunscreen Normal to Dry Skin 30 g RC0817 04/23 48.00 Set
40 Erha Rejuvenation Home Peeling Solution 30 ml QJ1348 10/22 2.00 Botol
41 ERHA Truwhite Active Glow 15 ml RE1250 06/22 29.00 Botol
42 ERHA Truwhite Body Brightening Cream 30 g QJ1477 10/22 9.00 Tube
43 ERHA Truwhite Brightening Body Moisturizer 250 g QK1873 12/22 13.00 Botol
44 Erha Truwhite Brightening Day Cream 30 g QI1361 09/22 10.00 Botol
45 ERHA Truwhite Brightening Neck Cream 30 g RA0003 01/23 18.00 Botol
46 Erha Truwhite Brightening Night Cream 30 g QJ1513 10/22 9.00 Botol
47 Erha Truwhite Niacinamide & Pineapple Enzyme Brightening Facial Wash 60 RA0199 01/23 26.00 Botol
ml
48 Erha Truwhite Niacinamide & TXA Brightening Face Toner 100 ml QRB0325 02/23 21.00 Botol
49 Erha Truwhite Vit C & Peptides Brightening Serum 20 ml RB0424 08/22 83.00 Botol
50 Erha21 DF Acne Care Lab Acne Back Spray 100 ml QL1896 12/22 19.00 Botol
51 Erha21 DF Acne Care Lab Acne Face Powder 21 g RB0316 03/23 27.00 Case
52 Erha21 DF Acne Facial Mask 20276002 03/24 91.00 Pieces
53 Erha21 DF Acne Facial Mask - 4 pcs 19D07009 06/23 12.00 Pack
54 Erha21 DF Age Corrector Day Moisturizer 30 g QE0705 05/22 15.00 Botol
55 Erha21 DF Age Corrector Night Moisturizer 30 g QH1175 08/22 12.00 Botol
56 Erha21 DF Brightening Facial Mask 20676002 08/23 88.00 Pieces
57 Erha21 DF Brightening Facial Mask - 4 pcs 20676002 08/23 19.00 Pack
58 Erha21 DF Collagen Mask for All Skin Types - 1 pc 20G001 07/23 12.00 Pieces
59 Erha21 DF Collagen Mask for All Skin Types - 4 pc 20H038 08/23 27.00 Pack
60 Erha21 DF Erha 10 Home Peeling 1 - 10 g RA0219 01/24 20.00 Pot
61 Erha21 DF Erha 11 Home Peeling 2 - 10 g QL1964 12/23 22.00 Pot
62 Erha21 DF Erha 2 Facial Wash for Oily Skin 60 ml RB0285 02/23 106.00 Botol
63 Erha21 DF Erha 3 Balancing Toner for All Skin Types 60 ml QL1963 12/23 49.00 Botol
64 Erha21 DF Erha 8 Moisturizer for Very Dry Skin 10 g RA0197 01/23 29.00 Pot
65 Erha21 DF Essential Moisturizer for All Skin Types 30 g QK1678 11/22 23.00 Botol
66 Erha21 DF Eternalips 8 g RB0255 02/24 18.00 Tube
67 Erha21 DF Evening Care Cream 1 - 15 g QH1174 08/22 5.00 Pot
68 Erha21 DF Exfoliating Cleansing Scrub for Very Oily Skin 60 g RA0211 01/23 95.00 Tube
69 Erha21 DF Perfect Shield UV A + UV B Sunscreen Gel for Oily Skin RA0183 01/23 41.00 Tube
70 Erha21 DF PS Helios Water Resistant SPF 50 PA++ 60 g RA0195 01/23 17.00 Tube
71 Erha21 DF Simply Remove 60 g RB0299 02/24 30.00 Tube
72 Erha21 DF Soothing Facial Mask 19D70001 01/23 49.00 Pieces
73 Erha21 DF Soothing Facial Mask - 4 pcs 19D70001 01/23 4.00 Pack
74 Erha21 DF Truwhite Activator Body Scrub 220 g QC0472 03/22 8.00 Tube
75 Erha21 DF Under Eye Suppressor 15 g RB0289 02/23 27.00 Botol
76 Erha21 DF Zinc Hya Ointment 15 g PC0423 03/22 7.00 Pot
77 Erhair DF Hair Grow Serum 7 x 8 ml QL1925 12/23 30.00 Box
78 Erhair DF Hair Grow Serum for All Hair Type 28 x 8 ml RB0366 02/23 13.00 Box
79 Erhair DF Hair Grow Shampoo 100 ml QG0979 07/22 22.00 Botol
80 Erhair DF Hair Grow Shampoo 250 ml RC0585 03/23 22.00 Botol
81 Erhair DF Hair Grow Shampoo 370 ml RC0711 03/23 25.00 Botol
82 Erhair DF Hair Grow Tonic 60 ml RC0460 03/23 39.00 Botol
83 Erhair Erazol Shampoo 100 ml RC0625 03/24 28.00 Botol
84 ERHAIR Restore Hair Moisturizer 125 g RB0295 02/23 28.00 Tube
85 ERHAIR Restore Shampoo 100 ml QH11168 08/22 8.00 Set
86 ERHAIR Restore Shampoo 250 ml QF0977 06/22 9.00 Set
87 ERHAIR Restore Shampoo 370 ml 8.00 Botol
88 ERHAIR Restore Shield Serum 100 ml 10.00 Botol
89 ERHAIR Scalperfect Exfoliating Gel 30 g QJ1482 10/22 7.00 Tube
90 Erhair Scalperfect Shampoo 100 ml QF0969 07/22 11.00 Botol
91 Erhair Scalperfect Shampoo 250 ml QG0970 07/22 12.00 Botol
92 Erhair Scalperfect Shampoo 370 ml QK1653 11/22 26.00 Botol
93 ERHAIR Scalperfect Soothing Serum 30 ml QJ1481 10/22 6.00 Botol
94 Erhalogy Brulief Skin Restoring Cream 60 g QG 1047 07/22 4.00 Tube
95 Erhalogy DF Hydrating Body Balm 125 g RC0532 03/23 11.00 Tube
96 Erhalogy DF Hydrating Body Wash for Very Dry and Mature Skin 100 ml RA0015 01/23 21.00 Botol
97 Erhalogy DF Intensive Moisturizer Carbamide 20% Cream 60 g QL2008 12/22 12.00 Tube
98 Erhalogy DF Skin Barrier Body Moisturizer 30 g RA0040 01/22 3.00 Tube
99 Erhalogy DF Skin Barrier Face Moisturizer 30 g QF0857 06/22 12.00 Tube
100 Erhalogy DF Skin Barrier Facial Wash for Dry & Sensitive Skin 60 g RB0342 02/23 27.00 Tube
101 Erhalogy Hydrating Body Balm 30 g QB0882 02/22 5.00 Tube
102 Erhalogy Pro Callus Gel 30 g QI1419 10/22 4.00 Tube
103 ESME DF Improved Formula Sureface Light Ivory 30 g RD0911 04/23 8.00 Botol
104 ESME DF Matte Sense Primer 20 g OA0146 01/23 15.00 Tube
105 ESME DF New Improved Formula Sureface Beige 30 g RD0908 04/23 5.00 Botol
106 ESME DF New Improved Formula Sureface Natural 30 g RD0909 01/23 6.00 Botol
107 ESME DF Refill Twin Silk Compact Powder Beige 13 PK2209 11/22 2.00 Pieces
108 ESME DF Refill Twin Silk Compact Powder Light Ivory 13 g QL2078 01/23 2.00 Pieces
109 ESME DF Refill Twin Silk Compact Powder Translucent 13 g QK1681 11/21 3.00 Pieces
110 ESME DF True Matte All Skin Types Translucent 15 g RA0041 01/24 24.00 Case
111 ESME DF True Matte Normal Skin Light Ivory 15 g EQC0482 04/22 5.00 Case
112 ESME DF True Matte Normal Skin Types Beige 15 g QD0578 04/22 4.00 Case
113 ESME DF True Matte Normal Skin Types Natural 15 g RA0046 01/23 6.00 Case
114 ESME DF True Matte Oily Skin Types Beige 15 g RA0044 01/23 7.00 Case
115 ESME DF True Matte Oily Skin Types Light Ivory 15 g Q11308 09/22 11.00 Case
116 ESME DF True Matte Oily Skin Types Natural 15 g QC0428 03/22 7.00 Case
117 ESME DF Twin Silk Compact Powder Beige 13 g QK2086 11/22 5.00 Case
118 ESME DF Twin Silk Compact Powder Light Ivory 13 g QD 1667 12/22 5.00 Case
119 ESME DF Twin Silk Compact Powder Natural 13 g QD0579 04/22 3.00 Case
120 ESME DF Twin Silk Compact Powder Translucent 13 g QK1667 11/22 4.00 Case
121 Feminax DEC19H09 12/24 4.00 Strip
122 Follicore Herbal RE100905/23 12/22 1,746.00 Capsule
123 Follicore Herbal 30 Kapsul RE100905/24 05/23 5.00 Box
124 Fusipar Cream 10 g QK1842 11/23 11.00 Tube
125 Glycore 10 Cream 10 g RA0179 01/23 23.00 Pot
126 Glycore 8 Cream 10 g QC0501 03/23 13.00 Pot
127 HIS ERHA Mattifying Clay 120 g 20E835A 11/23 9.00 Pot
128 HIS ERHA Waterbased Pomade 120 g 20PB298 07/23 13.00 Pot
129 HISERHA Acne Essence 60 ml QG1044 07/23 2.00 Botol
130 HISERHA Anti Dandruff Shampoo 270 ml QJ1483 10/22 13.00 Tube
131 HISERHA Booster Essence 60 ml QG1045 07/22 6.00 Tube
132 HISERHA Booster Facial Wash 100 g QJ1486 10/22 6.00 Tube
133 HISERHA Grey Hair Tonic 60 ml 20C09PB 04/23 26.00 Tube
134 HISERHA Hair Dust 12 g QF0928 07/22 10.00 Botol
135 HISERHA Hairgro Tonic 60 ml QJ1599 10/22 14.00 Botol
136 Littlerha DF Head To Toe Baby Wash Non Sls & Sles 300 ml RB0209 08/22 10.00 Botol
137 Littlerha Diaper Rash Cream 60 g QG1348 07/22 6.00 Tube
138 Littlerha Skin Barrier Body Moisturizer 100 g QG1150 08/22 8.00 Tube
139 Loracor 10 mg QL1906 12/23 310.00 Tablet
140 Mesone Cream 10 g RA0104 01/23 10.00 Tube
141 Mesone Gel 10 g QK1887 11/23 5.00 Tube
142 Mesone Ointment 10 g PK2089 12/22 15.00 Tube
143 Metcor 16 QC0440 03/23 133.00 Tablet
144 Metcor 4 QB0256 02/23 141.00 Tablet
145 Metcor 8 RB0313 02/24 114.00 Tablet
146 Minyak Kayu Putih Cap Lang 60 ml GR01815 03/26 1.00 Botol
147 Mupicor Cream 5 g RA0193 01/23 3.00 Tube
148 Mylanta Liquid 50 ml ED121092 12/22 1.00 Botol
149 OBH Combi 100 ml 0EE038 05/22 1.00 Botol
150 Panadol Reguler (Biru) OEC048 03/23 3.00 Strip
151 Pharmalene Gel 10 g QK1844 12/22 12.00 Tube
152 Promag 12's KTPPG091842 02/22 1.00 Strip
153 Reticor 0.025% Cream 15 g QL2088 01/23 12.00 Tube
154 Reticor 0.05% Cream 15 g QL2089 01/23 3.00 Tube
155 Skin Core QJ1472 10/22 893.00 Capsule
Yang Menerima, Yang Menyerahkan,
Apoteker Pengelola Apotik Baru Apoteker Pengelola Apotik Lama

apt. MG Niken Arumdati., S.Farm., apt. Drs. Stephanus Sugianto Setiawan.,

SIPA. srpA. 02t I 2.3s.1 I 3L.73.08 l -L.77 9.3 I 20t6

Saksi:

Yoan Kristin
Superuisor