BERITA ACARA SERAH TERIMA TANGGUNG JAWAB PELAYANAN

KEFARMASIAN

Pada hari ini, Rabu tanggal 30 Mei 2023

Sesuai dengan Keputusan Menteri Kesehatan Nomor : 1332/MENKES/SK/X/ tentang
Ketentuan dan Tata Cara Pemberian Izin Apotek, Kami yang bertanda tangan di bawah ini :

A. Apoteker Pengelola Apotek yang lama :

Nama Lengkap : apt. Dian Mardiana, S.Farm
Alamat : Dusun I Pujobasuki, RT/RW 004/002 Trimurjo,
Lampung Tengah
No. SIPA : 503/0027/049/D.b.VI.18/IX/2019
Tanggal SIPA : 4 September 2019
Nama Apotek : APOTEK FAEYZA FARMA
Alamat Apotek : Dusun I Sritejo Kencono, Kota Gajah, Lampung
Tengah

B. Apoteker Pengelola Apotek yang baru/pengganti :

Nama Lengkap : Apt. Agung Putu Surya Purna Kristyawan, S. Farm
Alamat : Jl. Yapeta No.1, Seputih Raman, Lampung Tengah,
Lampung
No. SIPA :-
Nama Apotek : APOTEK FAEYZA FARMA
Nomor SIA : 503/0018/063/D.b.VI.18/IX/2019
Alamat Apotek : Dusun I Sritejo Kencono, Kota Gajah, Lampung
Tengah

C. Dengan disaksikan oleh :

Nama : Ns. Refi Merinica, S.Kep
Alamat: Dusun III, RT/RW : 012/003, Saptomulyo, Kotagajah, Lampung Tengah
Jabatan : Pemilik Sarana Apotek
Telah melakukan penyerahan :
1. Obat-obat bebas, bebas terbatas, dan alat kesehatan.
2. Obat-obat keras tertentu/ bahan berbahaya
3. Menyerahkan arsip resep
4. Stok obat APOTEK FAEYZA FARMA per Mei 2023

Demikian Berita Acara Serah Terima Obat ini saya buat sesungguhnya dengan penuh
tanggung jawab.

Lampung Tengah, 30 Mei 2023

Yang Menerima Yang Menyerahkan

Apoteker Pengelola Apotek Baru Apoteker Pengelola Apotek Lama

Apt. Agung Putu Surya P, S. Farm apt. Dian Mardiana, S.Farm

SAKSI – SAKSI :
1. Ns. Refi Merinica, S.Kep (.........................................)
NO
. NAMA OBAT JUMLAH SATUAN
1 acifar 200 mg 9 strip
2 acifar 400 mg 3 strip
3 acifar cr 2 tube
4 acyclovir cr 16 tube
5 afitsone 3 botol
6 agarillus celte 3 botol
7 agarillus drop 4 botol
8 alkohol 1 lt 2 botol
9 alkohol pads 2 kotak
10 alleron 20 strip
11 alletrol 5 botol
12 allofar 100 mg 5 strip
13 allofar 300 mg 2 strip
14 allopurinol 100 mg 15 strip
15 allopurinol 300 mg 5 strip
16 alokohol 100ml 7 botol
17 alpara syr 5 botol
18 alpara tab 17 strip
19 ambeven 4 strip
20 ambroxol tab 10 strip
21 amlodipine 10 mg 12 strip
22 amlodipine 5 mg 113 strip
23 anacetin syr 5 botol
24 anakonidin 30 ml 2 botol
25 anastan 8 strip
26 anaton syr 6 botol
27 anaton tab 25 strip
28 andalan 3 bulan 1 ml 3 vial
29 anflat 8 strip
30 anflat syr 3 botol
31 antangin 45 sachet
32 antasida 21 strip
33 antasida syr 7 botol
34 antimo anak 15 sachet
35 antimo tab 6 strip
36 arkavit 17 strip
37 arkavit c 3 strip
38 balpirik 6 botol
39 balsem cincau 20gr 1 botol
40 balsem geliga 20gr 4 botol
41 balsem lang 20gr 6 botol
42 batugin 120 ml 2 botol
43 batugin 300 ml 1 botol
44 bejo 25 sachet
45 betadin 15ml 3 botol
46 betadin 5ml 3 botol
47 betadin cina 1 botol
48 betadin feminime 1 botol
49 betadin kumur 1 botol
50 betametasonen cr 8 tube
51 betason - n cr 3 tube
52 bevalex cr 4 tube
53 bintang 7 16 sachet
54 biocalsi 3 strip
55 biolysin kids tab 1 botol
56 biolysin smart syr 2 botol
57 biolysin syr 2 botol
58 bioplacenton cr 6 tube
59 bodrex 28 strip
60 bodrex extra 5 strip
61 bodrex f & e 11 strip
62 bodrex migra 3 strip
63 botol piegon 120 ml 3 botol
64 botol piegon 240ml 5 botol
65 braito 4 botol
66 brocitin flu syr 1 botol
67 broncitn exp syr 2 botol
68 bufacaryl 20 strip
69 bufacort cr 3 tube
70 bye fever anak 7 lembar
71 bye fever bayi 7 lembar
72 caladine 60 ml 2 botol
73 caladine baby 4 botol
74 caladine bedak 100 gr 4 botol
75 calcifar 22 strip
76 callusol 1 botol
77 calortusin 53 strip
78 canesten 4 tube
79 captropil 25 mg 46 strip
80 carbidu 0,5 mg 25 strip
81 carbidu 0,75 mg 24 strip
82 cataflam 9 tablet
83 cavicur 10 strip
84 cavicur syr 3 botol
85 caviplex 21 strip
86 caviplex cdez 9 strip
87 caviplex syr 4 botol
88 cazetin drop 4 botol
89 cdr 10's 2 botol
90 cendo polynel 1 botol
91 cendo xitrol 0 botol
92 cerebrofort syr 2 botol
93 ceteme 12 strip
94 cetirizine 53 strip
95 chili plast 51 roll
96 clonadrem cr 7 tube
97 coldrexin syr 3 botol
98 colfin plus syr 5 botol
99 colfin syr 5 botol
100 combatrin syr 6 botol
101 combatrin tab 5 strip
102 conterpain 30 gr 1 tube
103 contrexin 12 strip
104 cooling 5 biru 2 botol
105 cooling 5 orange 2 botol
106 coredryl syr 8 botol
107 corsaneuron 1 strip
108 counterpain 15 gr 4 tube
109 counterpain 5 gr 2 tube
110 ctm syr 5 botol
111 curcurma syr 0 botol
112 curviplex syr 4 botol
113 cyclofem inj 13 vial
114 daktarin 3 tube
115 danasone 86 strip
116 decadryl syr 2 botol
117 degirol 11 strip
118 dehista 16 strip
119 demacolin syr 2 botol
120 demacolin tab 24 strip
121 dettol cair 45ml 3 botol
122 dexaharsen 0,5 mg 25 strip
123 dexaharsen 0,75 mg 12 strip
124 dexanta 27 strip
125 dexanta syr 2 botol
126 dexigen cr 1 tube
127 dexteem plus 29 strip
128 diapet 7 strip
129 domperidon 6 strip
130 dramamine 0 tablet
131 dulcolax 10s 3 strip
132 dulcolax 4s 5 strip
133 earpick 2 pcs
134 eflagen 2 strip
135 em kapsul 6 kotak
136 emtunas forte 9 strip
137 emturnas 500mg 68 strip
138 enbatic tabur 31 sachet
139 entrasol gold 2 kotak
140 entronstop anak 4 sachet
141 entronstop tab 1 strip
142 epexol tab 5 strip
143 erladrem cr 4 tube
144 erlagin 21 strip
145 erlamicytin TM 4 botol
146 erlamycetin SM 4 tube
147 erlamycetin TT 4 botol
148 erlapect syr 0 botol
149 erpaflam 9 strip
150 estalex 2 strip
151 ester c 3 strip
152 etabion 6 strip
153 etaflusin tab 14 strip
154 etafulsin syr 3 botol
155 ever e 250 2 strip
156 eyevit 3 strip
157 fargetik 36 strip
158 farmoten 25 mg 7 strip
159 farsifen 200 17 strip
160 farsifen 400 26 strip
161 farsifen plus 15 strip
162 farsifen syr 5 botol
163 fasidol 500mg 39 strip
164 fasidol forte 10 strip
165 fasidol forte syr 6 botol
166 fasidol syr 8 botol
167 fatigon spirite 3 strip
168 fenamin 8 strip
169 fg troches 6 strip
170 fitkom tab 2 botol
171 fluanza syr 2 botol
172 flucadex tab 29 strip
173 flumin syr 5 botol
174 flumin tab 0 strip
175 flutamol syr 1 botol
176 flutamol tab 6 strip
177 flutop c syr 6 botol
178 folavit 11 strip
179 formula 44 anak 27 ml 4 botol
180 formula 44 anak 57 ml 4 botol
181 formula 44 dewasa 27 ml 9 botol
182 formula 44 dewasa 57 ml 5 botol
183 freshcare hijau 7 botol
184 freshcare merah 4 botol
185 fungiderm 5gr 3 tube
186 furosemide 4 strip
187 gandapura 30 ml 2 botol
188 gandapura 60 ml 3 botol
189 gasella 10 strip
190 gastrinal syr 1 botol
191 gastrucid syr 3 botol
192 gastrucid tab 22 strip
193 geliga 30 ml 1 botol
194 geliga 60 ml 2 botol
195 gemuk maxs 2 botol
196 genalten cr 3 tube
197 genoint SK 6 tube
198 genoint TM 5 botol
199 glibencamide 22 strip
200 glimepiride 2 mg 10 strip
201 glimepiride 4 mg 10 strip
202 gom 6 botol
203 gomars 5 kotak
204 gpu cair 30 ml 2 botol
205 gpu cair 60 ml 4 botol
206 gpu cr 150 gr 1 tube
207 gradilex 5 strip
208 grafaclor 22 strip
209 grafadon 12 strip
210 grafadon syr 1 botol
211 grafalin 2 mg 16 strip
212 grafalin4 mg 9 strip
213 grafamic 5 strip
214 grantusif 11 strip
215 grathazone 27 strip
216 gratheos 18 strip
217 grazeo 43 strip
218 griseofulvin 23 strip
219 handgel nuvo 85ml 6 botol
220 hansaplast 81 pcs
221 hanscoon 76 pcs
222 hemaviton action 7 strip
223 hemaviton stamina 13 strip
224 herocyn b 2 botol
225 herocyn k 2 botol
226 hevit c 1000mg 8 strip
227 hevit c 500mg 5 strip
228 hico gel 2 tube
229 histigo 14 strip
230 holizinc syr 3 botol
231 hormoviton 2 strip
232 hot in cream botol ori 120 gr 4 botol
233 hot in cream botol sorong 120 gr 2 botol
234 hot in cream botol strong 60 gr 4 botol
235 hot in cream botol strong 60 gr 5 botol
236 hot in cream tube hijau 60 gr 5 tube
237 hot in cream tube ori 120 gr 1 tube
238 hot in cream tube ori 60 gr 3 tube
239 hot in cream tube strong 120 gr 1 tube
240 hot in cream tube strong 60 gr 3 tube
241 hot in dcl 60 gr 1 tube
242 hufabetamin syr 6 botol
243 hufabion 6 strip
244 hufagesic 65 strip
245 hufagesic syr 4 botol
246 hufagrif biru syr 4 botol
247 hufagrif hijau syr 6 botol
248 hufagrif kuning syr 6 botol
249 hufagrif merah syr 6 botol
250 hufagrip forte 22 strip
251 hufamag 21 strip
252 hufamag syr 2 botol
253 hustarex syr 6 botol
254 hydrocortisone cr 12 tube
255 ichtiyol 6 botol
256 imboost force tab 16 tablet
257 imboost kids syr 0 botol
258 inerson 1 tube
259 inflagin 3 strip
260 inflasone 31 strip
261 insto 5 botol
262 itramag 6 strip
263 itrasal syr 12 botol
264 kaditic 21 strip
265 kalmetashone 59 strip
266 kalpanak slp 4 tube
267 kalpanax cr 5 tube
268 kandistatin drop 2 botol
269 kanna 1 kotak
270 kaotin syr 5 botol
271 kapas 5 roll
272 kapsida 4 botol
273 kapsul daun katuk 4 botol
274 kasa gulung 10cm 54 roll
275 kasa gulung 15cm 55 roll
276 kasa steril 20 kotak
277 kejibeling 0 strip
278 kembang bulan slp 6 tube
279 ketoconazole 16 strip
280 ketoconazole cr 8 tube
281 klorfeson cr 2 tube
282 komix herbal 9 sachet
283 konicare bedak 1 botol
284 konidin 8 strip
285 kool fever anak 7 lembar
286 kool fever bayi 9 lembar
287 koyo salonpas 8 sachet
288 koyo cabe 10 sachet
289 laxing 4 strip
290 lambucid syr 2 botol
291 lanadexon 17 strip
292 lancar asi 4 strip
293 lancet 2 kotak
294 lansoprazole 5 strip
295 latibet 1 strip
296 lerzin 7 strip
297 leukoplast 11 roll
298 lexacrol 11 strip
299 licodexon 31 strip
300 licokalk 39 strip
301 listerin 100ml 1 botol
302 listerin 240 ml 1 botol
303 livron b plex 13 strip
304 lokev 13 strip
305 lotte 1 botol
306 lumbric 3 botol
307 maag gel syr 3 botol
308 madu hitam pahit 2 botol
309 madu hutan 1 botol
310 madu tj joybee 5 botol
311 madu tj murni btl 6 botol
312 madu tj sacet 195 sachet
313 magic power hitam 3 kotak
314 magic power merah 4 kotak
315 mantino 6 strip
316 masker duckbil 42 lembar
317 masker hijab 207 lembar
318 masker telinga 226 lembar
319 mecobalamin 9 strip
320 mefinal 500 3 strip
321 meloxicam 15 mg 0 strip
322 meloxicam 7,5 mg 9 strip
323 metformin 19 strip
324 methylprednisone 4 mg 14 strip
325 mexon 38 strip
326 mezac 16 strip
327 miconazole cr 6 tube
328 microlax 3 tube
329 minyak but but 3 botol
330 minyak kapak 10ml 3 botol
331 minyak kapak 14ml 2 botol
332 minyak kapak 3ml 1 botol
333 minyak kapak 56ml 1 botol
334 minyak kapak 5ml 2 botol
335 minyak zaitun 60ml 3 botol
336 miracloven 26 strip
337 mirasic 500mg 54 strip
338 mirasic forte 12 strip
339 mirasic plus 15 strip
340 mixagrif flu 12 strip
341 mixalgin 23 strip
342 mkp 120 ml 2 botol
343 mkp 15ml 22 botol
344 mkp 30ml 27 botol
345 mkp 60ml 15 botol
346 molafate syr 1 botol
347 molexflu tab 57 strip
348 mycoral cr 5 tube
349 mycoral tab 44 tablet
350 mylanta syr 4 botol
351 mylanta tab 12 strip
352 napacin 22 strip
353 natur e 100 0 strip
354 natur e 300 4 strip
355 neclo 100 ml 1 botol
356 nelco 55 ml 3 botol
357 neprolit 3 strip
358 neuralgin RX 13 strip
359 neurobion pink 4 strip
360 neurobion putih 2 strip
361 neurodex 28 strip
362 nippleshield 2 strip
363 nisagon 4 tube
364 nosip 2 tube
365 novakal 25 strip
366 ob herbal syr 2 botol
367 obh berlico syr 1 botol
368 obh combi plus 100 ml 7 botol
369 obh combi plus 60 ml 13 botol
370 obh combi plus anak 60 ml 5 botol
371 obh combi regular 100 ml 8 botol
372 ocuson 9 strip
373 oktabumin 2 botol
374 omedom tab 13 strip
375 omeprazole 12 strip
376 omeroxol tab 14 strip
377 ondasetron 4 mg 8 strip
378 opistan 18 strip
379 orpen 20 strip
380 oskadob biasa 11 strip
381 oskadon sp 13 strip
382 oxicobal 4 strip
383 pacdin cough syr 2 botol
384 padandol biru 3 strip
385 panadol merah 2 strip
386 paraflu 14 strip
387 paramex biasa 7 strip
388 paramex nyeri otot 4 strip
389 paratusin syr 3 botol
390 paratusin tab 11 strip
391 peditox 3 botol
392 perban elastis 3 roll
393 pil kb andalan 79 roll
394 pim tra kol cherry 6 botol
395 pim tra kol stawbery 6 botol
396 piroxicam kaps 7 strip
397 piroxicam tab 20 strip
398 pk 19 tube
399 plantacid syr 1 botol
400 polofar plus 28 strip
401 polysilane syr 1 botol
402 polysilane tab 7 strip
403 pompa susu 3 botol
404 pondex 11 strip
405 pp test onehealth 78 pcs
406 pp test onemed 61 pcs
407 pregcy pp test 3 pcs
408 procurma syr 3 botol
409 promag 12 strip
410 proris syr 2 botol
411 quantidex syr 1 botol
412 quantidex tab 5 strip
413 ranitidine 24 strip
414 redoxon 10's 4 botol
415 renadinac 28 strip
416 rhemafar 8 strip
417 rheumacyl 4 strip
418 rivanol 100ml 8 botol
419 rohto cool 8 botol
420 roverton syr 8 botol
421 roverton tab 14 tube
422 sabun asepso 3 kotak
423 sakatonik abc 6 botol
424 salbron syr 2 botol
425 salbutamol 2 mg 11 strip
426 salbutamol 4 mg 12 strip
427 salep 88 6 tube
428 salicyl kf 13 tube
429 samcofenac' 45 strip
430 samtacid 13 strip
431 sanadryl dmp 120 ml 3 botol
432 sanadryl DMP 60 ml 3 botol
433 sanadryl exp 120 ml 1 botol
434 sanadryl exp 60 ml 3 botol
435 sangobin syr 2 botol
436 sangobion 10's 8 strip
437 sangoibion 4's 3 strip
438 sanmag syr 3 botol
439 sanmol 500mg 20 strip
440 sanmol drop 3 botol
441 sanmol forte 26 strip
442 sanmol syr 6 botol
443 sarikurma angkak 2 botol
444 sarikurma super 1 botol
445 scabimite 0 tube
446 scoots emulsion syr 1 botol
447 selediar 6 strip
448 seremig 3 strip
449 siladex ATT 60 ml 6 botol
450 siladex ME 30 ml 4 botol
451 siladex ME 60 ml 2 botol
452 siladex cc 60 ml 6 botol
453 simvastatin 10 mg 17 strip
454 simvastatin 20 mg 10 strip
455 solinfec cr 3 tube
456 solinfec tab 3 strip
457 spasminal 7 strip
458 stimuno syr 2 botol
459 sucrafate syr 2 botol
460 sutra hitam 12s 6 kotak
461 sutra hitam 3s 2 pcs
462 sutra merah 12s 5 kotak
463 sutra merah 3s 16 pcs
464 tawon cc 2 botol
465 tawon dd 3 botol
466 tawon ee 2 botol
467 telon lang 15ml 1 botol
468 telon my baby 150ml 1 botol
469 telon my baby 30ml 6 botol
470 telon my baby 60ml 7 botol
471 telon my baby 90ml 3 botol
472 tempra syr 0 botol
473 teosal 32 strip
474 tera f 56 strip
475 termorex plus 30 ml 1 botol
476 thermometer 1 pcs
477 tifalsic 14 strip
478 tolak angin anak 35 sachet
479 tolak angin dewasa 41 sachet
480 tolak linu jahe 16 sachet
481 tolak linu mint 20 sachet
482 trianta 24 strip
483 trimakalk 35 strip
484 triocid 11 strip
485 tuntas 2 kotak
486 ultracyn anak 4 botol
487 ultracyn dewasa 5 botol
488 ultrafix 10x5 2 kotak
489 ultrafix 5x5 0 kotak
490 ultraflu 10 strip
491 ultrasiline 7 tube
492 underpad 2 pak
493 v fresh 1 botol
494 vasperum 5 strip
495 vastigo 5 strip
496 ventolin nebu 6 pcs
497 vice 132 pcs
498 vicks vaporub 10gr 5 tube
499 vicks vaporub 20gr 0 tube
500 vidoran tab 1 botol
501 viostin 2 strip
502 virgo pro kapsul 2 botol
503 vit b1 ipi 9 botol
504 vit b comp ipi 8 botol
505 vit c ipi 10 botol
506 vital 6 botol
507 voltadex 39 strip
508 waisan 8 kotak
509 welmove 1 strip
510 wiros 39 strip
511 woods ATT 60 ml 1 botol
512 woods exp 60 ml 2 botol
513 yeakdryl syr 2 botol
514 zecaneuron 19 strip
515 zelona 54 strip
516 zinc tab 17 strip
517 zoralin cr 3 tube
518 zoralin tab 19 strip