SP Prekursor

Mei 2018 1
2 MNJ
3 APL
4 Sri buana
Juni 1 aam
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5 ssi
6 MNJ
7 Kebayoran
8 Enseval
juli 1 apl
agust
SURAT PEMESANAN OBAT MENGANDUNG PREKURSOR FARMASI
No. SP : 16/3/2017
Yang bertanda tangan di bawah ini :

Nama : Bayu Herdi Al Huda, Apt
Jabatan : Apoteker Penanggung jawab Apotek
Nomor SIPA : 440/1774/SIPA/429.114/IX/2016
Mengajukan pesanan obat mengandung Prekursor Farmasi kepada :
Nama PBF : PARIT PADANG GLOBAL
Alamat : Jl teuku Umar 68
Telp : 0331-333318
Jenis obat mengandung Prekursor Farmasi yang dipesan adalah :
Nama Obat Mengandung Zat Aktif Prekursor Bentuk

No Satuan Jumlah
Prekursor Farmasi Farmasi Sediaan
1 Asthma Soho Ephedrine 12,5 mg Tab Dus 3

2
3
Obat tersebut akan digunakan untuk memenuhi kebutuhan Apotek :

Nama Sarana : Apotek Kimia Farma No. 307
Alamat Lengkap : JL AHMAD YANI 72 BANYUWANGI
No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,
Apoteker Penanggung jawab
Bayu Herdi Al Huda, Apt

440/1774/SIPA/429.114/IX/201
No. SP : 004/IX/2018

Nama : Ditha Violy Nindyasari, S.Farm., Apt.
Nomor SIPA : 440/2329/SIPA/429.114/II/2017
Nama PBF : Merapi Utama
Alamat : Jalan letjen Sutoyo, 87 Jember
Telp : 0331-324717
Nama Obat Mengandung Bentuk

No Zat Aktif Prekursor Farmasi Satuan Jumlah
Prekursor Farmasi Sediaan
1 Nasafed Syr 60 Ml Pseudoefedrin 15 mg Sirup Botol -

2 Nasafed Tab Pseudoefedrin 60 mg Tablet Box -
3 Nasafed Plus Tab Pseudoefedrin 60 mg Tablet Box -
Dextrometorphan 7.5 mg
4 Hufagrip BP Sirup Botol -
Pseudoefedrin 15 mg
5 Hufagrip Pilek Syr Pseudoefedrin 15 mg Sirup Botol -
6 Hufagrip Syr Pseudoefedrin 15 mg Sirup Botol 2
Dextrometorphan 15 mg
7 Mucotussan Tab Tablet Box -
Phenylpropanolamin 12.5 mg

Nama Sarana : Apotek Kimia Farma Genteng
Alamat Lengkap : JL Diponegoro No. 07 Genteng Banyuwangi
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
Ditha Violy Nindyasari,S.Farm.,Apt.

440/2329/SIPA/429.114/II/2017
SURAT PEMESANAN OBAT
No. SP : 001/IX/2018

Mengajukan pesanan obat kepada :
Alamat : Jl Letjen Sutoyo, 87 Jember
Telp : 0331-324717
Jenis obat yang dipesan adalah :

No Zat Aktif OOT Farmasi Satuan Jumlah
OOT Farmasi Sediaan
1 Arkine 2 mg Trihexyphenidil 2 mg Kaplet Dus -

2 Haloperidol 5 mg Haloperidol 5 mg Tablet Dus -
3 Patral Tramadol HCl 37.5 Mg Kaplet Dus -
4 Tramadol 50 mg Tramadol HCl 50 Mg Kapsul Dus -
5 Hexymer 2 mg Trihexyphenidil 2 mg Tablet Dus -
6 Merlopam 2 mg Lorazepam 2 mg Tablet Dus -
7 Risperidone 2 mg Risperidone 2 mg Tablet Dus -
8 Bamgetol Carbamazepin 200 mg Tablet Dus -
9 Hufagrip BP Sirup Botol 6
Pseudoefedrin 15 mg

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : / /

Nama PBF : Tempo
Alamat : Jalan Teuku Umar No. 87 Jember
Telp : 0331-322818
Nama Obat Mengandung Prekursor Bentuk

Farmasi Sediaan
1
2 Bodrexin Pilek Alergi 56 Pseudoephedrine HCl 7.5mg Sirup Botol 30
3
4
5
6
7
8
9
10

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
No. SP : 105/4/2017

Nama PBF : Tempo
Telp : 0331-322818
Bentuk
No Nama Obat Satuan Jumlah
Sediaan
1 Bodrexin Flu & Batuk Syr 56ml Sirup Botol 25

2
3 Bodrex flu dan batuk kpl@100 Tablet Dus 5
4 Bodrex flu & btk berdahak tab @100 Tablet Box 5
5 Bodrex Migra Tab Tablet Box 3
6 Bodrex Extra Tab Tablet Box 3
7 Bodrex Tab @ 20 Tablet Box
8
9
10

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
No. SP : 005/IX/2018

Nama PBF : Marga Nusantara Jaya
Alamat : Jalan Sentot Prawirodijo No. 30 Jember
Telp : 0331-487380
Nama Obat Mengandung Prekursor Zat Aktif Prekursor Bentuk &

No Satuan Jumlah
Farmasi Farmasi Kekuatan
1 Termorex Plus 30 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 3
2 Termorex Plus 60 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 7
3 Anakonidin 30 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol -

4 Anakonidin 60 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 5
5 Anakonidin OBH 30 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 2
6 Anakonidin OBH 60 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 3
7 Siladex CC 30 ml Pseudoephedrin HCl 15 mg/ 5 ml Botol -
10 Inza Kaplet Pseudoephedrin HCl 30 mg/ kaplet Dus -
11 Paramex Flu & Batuk Pseudoephedrin HCl 30 mg/ tablet Dus -
12 Neo Napacin Pseudoephedrin HCl 12.5 mg/ tablet Dus 1
10 Inza Syrup 60 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol -
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 004/IX/2018

Nama : Ditha Violy Nindyasari, S.Farm., Apt
Nama PBF : Bina San Prima
Alamat : Jalan Letjen Sutoyo No. 138 Jember
Telp : 0331-324033

Farmasi Sediaan
1 Tremenza Syr 60ml Pseudoephedrine HCl 30mg Sirup Botol -
2 Tuzalos 15mg Kpl Dextromethorphan HBr 10mg Kaplet Box 1
3 Aldisa SR Cap Pseudoephedrine SO4 120mg Kapsul Box -
4 Sanaflu Forte Tab Dextromethorphan HBr 7.5mg Kapsul Box -
5 Sanaflu Tab Dextromethorphan HBr 7.5mg Kapsul Box -
6 Tremenza tab Pseudoephedrine HCl 30mg Kaplet Box 1
7 Sanaflu plus syr Dextromethorphan HBr 7.5mg Sirup Botol 3
8 Sanaflu plus batuk syr 60 ml Dextromethorphan HBr 7.5mg Sirup Botol 3
9 Sanaflu plus batuk tab @100 Dextromethorphan HBr 7.5mg Kaplet Box -
10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
Ditha Violy Nindyasari,S.Farm.,Apt

440/2329/SIPA/429.114/II/2017
SURAT PEMESANAN OBAT MENGANDUNG OBAT TERTENTU
No. SP : 17/3/2017

Mengajukan pesanan obat mengandung OOT Farmasi kepada :
Nama PBF : Bina San Prima
Telp : 0331-324033
Jenis obat mengandung OOT Farmasi yang dipesan adalah :

No Zat Aktif OOT Farmasi Satuan Jumlah Ket
OOT Farmasi Sediaan
1 Tradosik 50 MG Cap Tramadol HCL 50 Mg Tab Dus 2

2

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
No. SP : 007/VIII/2018

Nama PBF : Mensa Bina Sukses
Alamat : Jalan KH Sidik No. 110 No. Jember
Telp : 0331-482332

No Zat Aktif Prekursor Farmasi Satuan Jumlah Ket
Farmasi Sediaan
1 Fludane Plus Syr Phenylpropanolamin, DMP Sirup Botol 3
2 Trifed Syr 60 Ml Pseudoefedrin HCl Sirup Botol 3
3 Trifed Tab Pseudoefedrin HCl Kapsul Box 1
4 Fludane Kapl Phenylpropanolamin Kapsul Box 1
5 Fludane Plus Kpl DMP, Phenylpropanolamin Kapsul Box 1
6 Fludane Forte Cap Phenylpropanolamin Kapsul Box 1
7 Fludane Syr Jeruk Phenylpropanolamin Sirup Botol 3
8 Alpara KPL Dextrometorphan Hbr 15 Mg Kapsul Box 1
9 Dextral DMP, Phenylpropanolamin Kapsul Box 1
10 Dextral Forte DMP, Phenylpropanolamin Kapsul Box 1

Alamat Lengkap : JL Diponegoro No.07 Genteng Banyuwangi
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 003/IX/2018

Nama PBF : Enseval Putra Megatrading
Alamat : Jalan Monginsidi, 889 Ajung, Jember
Telp : 0331-335000
Nama Obat
Bentuk
No Mengandung Zat Aktif Prekursor Farmasi Satuan Jumlah
Sediaan
Prekursor Farmasi
1 Mixagrip Flu Phenylpropanolamin 25 Mg Tablet Box 1
Pseudoefedrin
2 Mixagrip Flu & Batuk Tablet Box 1
Dextrometorfan
3 Procold Tab Pseudoefedrin 30 mg Tablet Box 2
Dextrometorfan 8 mg
4 Mextril Syrup Sirup Botol -
PPA 12 mg
5 Mextril Tab Dextrometorfan 15 mg Tablet Box -
DMP 10 mg
6 Mixadin Tablet Box -
Efedrin 12,5
7 Komix Jahe Dextrometorfan Sachet Box 2
8 Komix Peppermint Dextrometorfan Sachet Box 2
9 Komix Herbal Dextrometorfan Sachet Box 2
10 Komix Kid Strawberry Dextrometorfan Sachet Box 2
11 Komix Jeruk Nipis Dextrometorfan Sachet Box 2
12 Komix Kid Madu Dextrometorfan Sachet Box 2
13 Promedex Tab Dextromethorphan HBr Tablet Box 4
14 Anadex Drage DMP, Phenylpropanolamin Kapsul Box -
15 Anadex Syr 60 ml DMP, Phenylpropanolamin Sirup Botol -
16 Alco oral drop 15 ml Pseudoefedrin HCl 30 Mg Sirup Botol 10
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 003/IX/2018

Nama PBF : Anugrah Argon Medika
Telp : 0331-326717
Nama Obat Mengandung Prekursor Bentuk Sediaan dan Jumlah(angk

No
Farmasi Kekuatan/Potensi Kemasan Satuan a&huruf)
1 Rhinofed Tablet Tablet, 30 mg Tablet Box 2 (dua)
2 Rhinofed Suspensi 60 ml Suspensi, 15 mg/5ml Botol Botol -
3 Rhinos SR Kapsul Lepas Lambat 120 mg Kapsul Box 4 (empat)
4 Rhinos Junior Syrup 60 ml Syrup, 15 mg/ 5 ml Botol Botol -
5 Rhinos Neo Drop Larutan, 7.5 mg/0.8 ml Botol Botol -
6
7

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 003/VI/2018

Nama PBF : Anugrah Pharmindo Lestari
Telp : 0331-324717

Farmasi Sediaan
1 Aerius D-12 Tablet Pseudoefedrin Sulfat Tablet, 120 mg Box -

2 Clarinase Tab 50s Pseudoefedrin Sulfat Tablet, 120 mg Box -
3 Telfast Plus Pseudoefedrin HCl Tablet, 120 mg Box -
4 Cafergot 100 mg Ergotamin tartrat Tablet, 1 mg Box -
5 OBH Combi Batuk Flu Jahe Syr 100ml Efedrin HCl Sirup, 2.5 mg Botol 5
7 OBH Combi Batuk Flu Madu Syr 100 ml Efedrin HCl Sirup, 2.5 mg Botol 6
9 OBH Combi Batuk Flu Menthol Syr 100 ml Efedrin HCl Sirup, 2.5 mg Botol 3
11 OBH Combi Batuk Flu Anak Apel Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol 6
12 OBH Combi Batuk Flu Anak Madu Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol 7
13 OBH Combi Batuk Flu Anak Strawberry Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol 4
14 OBH Combi Batuk Flu Anak Jeruk Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol 6
15 Tusapress Elixir Efedrin HCl Sirup, 12.5 mg Botol -
16 Neo Triaminic Drop Pseudoefedrin HCl Drop, 7.5 mg Botol -
17 Triaminic Batuk & Pilek Pseudoefedrin HCl Sirup, 15 mg Botol 5
18 triaminic Pilek Pseudoefedrin HCl Sirup, 15 mg Botol -
19 Triaminic Exp & Pilek Pseudoefedrin HCl Sirup, 15 mg Botol 9
20 Stop Cold Dragee Pseudoefedrin HCl Tablet, 30 mg Box -
21 Allerin Exp Syr 120 ml Pseudoefedrin HCl Sirup, 15 mg Botol -
22 Allerin Exp Syr 60 ml Pseudoefedrin HCl Sirup, 15 mg Botol -
23 Decolsin Caps Phenylpropanolamine Kapsul, 12.5 mg Box 1
24 Decolsin Syr Pseudoefedrin HCl Sirup, 15 mg Botol -
25 Paratusin Tab Phenylpropanolamine Tablet, 12.5 mg Box 1
26 Paratusin Syr Pseudoefedrin HCl Sirup, 15 mg Botol 2
27 Decolgen PSE Liq Pseudoefedrin HCl Sirup, 7.5 mg Botol -
28 Decolgen FX Pseudoefedrin HCl Tablet, 30 mg Box -
29 Decolgen Tab Phenylpropanolamine Tablet, 12.5 mg Box -
30 Asmasolon Tab Efedrin HCl Tablet, 12.5 mg Box -
31 Nalgestan Tab Phenylpropanolamine Tablet, 15 mg Box -
32 Neozep Forte Tab Blister Phenylpropanolamine Tablet, 12.5 mg Box -
33 Neozep Forte Tab Phenylpropanolamine Tablet, 15 mg Box -
37 Actifed Syr 120 ml Pseudoefedrin HCl Sirup, 30 mg Botol -
39 Actifed Plus Cough Suppresant Syr 120 ml Pseudoefedrin HCl Sirup, 30 mg Botol -
40 Actifed Plus Cough Suppresant Syr 60 ml Pseudoefedrin HCl Sirup, 30 mg Botol 3
41 Actifed Plus Expectorant Syr 120 ml Pseudoefedrin HCl Sirup, 30 mg Botol -
42 Actifed Plus Expectorant Syr 60 ml Pseudoefedrin HCl Sirup, 30 mg Botol 8
43 Panadol Cold & Flu 100s Pseudoefedrin HCl Kaplet, 30 mg Box -

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017
No. SP : 009/VIII/2018

Nama : Ditha Violy Nindyasari,S.Farm., Apt.
Nama PBF : Millenium
Alamat : Jl. Kertanegara, 210 Jember
Telp :
Nama Obat
Bentuk
No Mengandung Prekursor Zat Aktif Prekursor Farmasi Satuan Jumlah
Sediaan
Farmasi
1 Lapifed DM Syr 100ml Pseudoephedrine HCl 30 mg; DMP hbr 10 mg Sirup Botol 3
2 Lapifed Exp Syr 60ml Pseudoepherine HCl 15mg Sirup Botol -
3 Lapifed Tab Pseudoepherine HCl 60mg Tablet Dus 1
4 Lapifed Syr Pseudoepherine HCl 15mg Sirup Botol 1
5 Intunal F Tab DMP HBr 15 mg, PPA 15 mg Tablet Dus 1
6 Intunal Kpl DMP HBr 7.5 mg, PPA HCl 6 mg Tablet Dus -
7 Lapisiv Syr DMP HBr 7.5 mg, PPA HCI 6 mg Sirup Botol -
7 Lapisiv Tab dextromethorphan HBr 10 mg, Tablet Dus -
No. Izin Sarana : 503.445/26/429.114/2017
Banyuwangi,
Ditha Violy Ninidyasari,S.Farm.,Apt

440/2329/SIPA/429.114/II/2017
SURAT PEMESANAN OBAT - OBATAN TERTENTU

Telp :
Nama Obat Mengandung OOT Bentuk

Farmasi Sediaan
1 Analtram Tramadol HCl 37.5 mg Tablet Dus 3

2
3

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016

Telp :
No Nama Obat Bentuk Sediaan Satuan Jumlah
1 FG TROCHES Tablet Dus 6

2 LAPIBAL 500 ug Tablet Dus 1
3

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
No. SP : 207/3/2017

Nama PBF : PT Kalista Prima
Alamat : Jl. Biliton, 14 Gubeng Surabaya
Telp :
Nama Obat
Bentuk
No Mengandung Prekursor Zat Aktif Prekursor Farmasi Satuan Jumlah
Sediaan
Farmasi
1 Lapifed DM Syr 100ml pseudoephedrine hcl 30 mg; DMP hbr 10 mg Sirup Botol
2 Lapifed Exp Syr 60ml Pseudoepherine HCl 15mg Sirup Botol
3 Lapifed Tab Pseudoepherine HCl 60mg Tablet Dus 6
4 Lapifed Syr Pseudoepherine HCl 15mg Sirup Botol
5 Intunal F Tab DMP HBr 15 mg, PPA 15 mg Tablet Dus
6 Intunal Kpl DMP HBr 7.5 mg, PPA HCl 6 mg Tablet Dus
7 Lapisiv Syr DMP HBr 7.5 mg, PPA HCI 6 mg Sirup Botol
7 Lapisiv Tab dextromethorphan HBr 10 mg, Tablet Dus
No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
No. SP : 007/VI/2018

Nama PBF : Kebayoran
Alamat : Jalan Nusantara V No. 12A Blok C Jember
Telp : 0331-423743

1 Alpara Kpl DMP HBr 15mg Kapsul Box/150 1

2 Dextral Cap DMP HBr 10mg, PPA HCl 12.5mg Kapsul Box/150 1
3 Dextral Forte Cap DMP HBr 15mg, PPA HCl 15mg Kapsul Box/150 1
4
5

Alamat Lengkap : JL Diponegoro No.07 Genteng
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
Ditha Violy Nindyasari, S.Farm., Apt

440/2329/SIPA/429.114/II/2017
No. SP : 012/VIII/2018

Nama PBF : Sapta Sari Tama
Alamat : Jalan teuku Umar, Perum Sumber Bendo Blok C No. 41 Jember
Telp : 0331-337065

Farmasi Sediaan
Dextromethorphan HBr 15mg,
1 Antiza Drage Tablet Box/100 1
Phenylpropanolamine HCl 12.5mg
2 Halmezin Syr 100ml Dextromethorphan HBr 7.5mg Sirup Botol 6
3 Fludane syr Phenylpropanolamin Sirup Botol 3
4 Fludane Kapl Phenylpropanolamin Kapsul Box 1
5 Fludane Plus Kapl DMP, Phenylpropanolamin Kapsul Box 1
6 Fludane Forte Kapl Phenylpropanolamin Kapsul Box 1
7 Antiza Syr Dextromethorphan HBr 15mg Sirup Botol 3
8 OBH Tropica + Anak 60ml Jeruk Pseudoephedrine HCl 7.5mg Sirup Botol 3
9 OBH Tropica + Anak 60ml Straw Pseudoephedrine HCl 7.5mg Sirup Botol 3
10 OBH Tropica Extra menthol 100 Ml Pseudoephedrine HCl 7.5mg Sirup Botol 3
11 OBH Tropica + DWS 60 Ml Menthol Pseudoephedrine HCl 7.5mg Sirup Botol 3
12 OBH Tropica + DWS 100 Ml Menthol Pseudoephedrine HCl 7.5mg Sirup Botol 3
13 Fludane Plus Syr DMP, Phenylpropanolamin Sirup Botol 3
14 Halfilyn Syr 100ml Pseudoephedrine HCl 25mg Sirup Botol 6
Alamat Lengkap : JL Diponegoro No.07 Genteng
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
Ditha Violy Nindyasari, S.Farm.,

440/2329/SIPA/429.114/II/2017
No. SP : 003/VIII/2018

Nama : Ditha Violy Nindyasari, S.Farm., Apt
Nama PBF : PT. Lenko Surya Perkasa
Alamat : Rambipuji
Telp : 082338858388
Nama Obat Mengandung Prekursor Zat Aktif Prekursor Bentuk

No Satuan Jumlah
Farmasi Farmasi Sediaan
1 OBH Nellco Special 100ml Jahe Ephedrine HCl Sirup Botol 3
2 OBH Nellco Special 100ml Madu Ephedrine HCl Sirup Botol 3
3 OBH Nellco Special 100ml Menthol Ephedrine HCl Sirup Botol 8
4 OBH Nellco Special 100ml Anak Jeruk Ephedrine HCl Sirup Sirup 6
5 OBH Nellco Special 100ml Anak Straw Ephedrine HCl Sirup Sirup 6

Alamat Lengkap : JL. Diponegoro No. 07 Genteng Banyuwangi
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
Ditha Violy Nindyasari.,S.Farm.

440/2329/SIPA/429.114/II/2017
No. SP : 010/VIII/2018

Nama : Ditha Violy Nindyasari, S. Farm., Apt.
Nama PBF : Sribuana Sumber Lestari
Alamat :
Telp : 031-3821110

Farmasi Sediaan
1 Demacolin Tab Dextrometorphan 7.5mg Tablet Box/100 -
2 Ultraflu Tab Phenylpropanolamine 12.5 mg Tablet Box/100 -
3 Demacolin Syr Dextrometorphan 7.5mg Sirup Botol -
4 Halfilyn Syr Dextromethorphan HBr 7.5mg Sirup Botol -
5 Pimtrakol cherry syr 60ml Efedrin HCl Sirup Botol -
6 Pimtrakol lemon syr 60ml Efedrin HCl Sirup Botol -
7 Komix Herbal Dextrometorfan Sachet Box 2

Alamat Lengkap : Jl. Diponegoro No.07 Genteng Banyuwangi
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 005/VI/2018

Nama PBF : PT Sejahtera Surya Intrio
Alamat : Jalan Ngagel Jaya Utama 106 Surabaya
Telp : 031-5014086

Farmasi Sediaan
1 Demacolin Tab Dextrometorphan 7.5mg Tablet Box/100 5
2 Ultraflu Tab Phenylpropanolamine 12.5 mg Tablet Box/100 1
3 Demacolin Syr Dextrometorphan 7.5mg Sirup Botol 6
4 Halfilyn Syr Dextromethorphan HBr 7.5mg Sirup Botol 6
5 Pimtrakol cherry syr 60ml Efedrin HCl Sirup Botol 15
6 Pimtrakol lemon syr 60ml Efedrin HCl Sirup Botol 15

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
SURAT PEMESANAN OBAT MENGANDUNG OBAT TERTENTU
No. SP : 20/I/2017
.
Nama PBF : Kimia Farma Trading & Distribution
Alamat : Jl Dr Subandi, 60 Patrang Jember
Telp : 0331-421680

No Zat Aktif OOT Farmasi Satuan Jumlah Ket
OOT Farmasi Sediaan
1 Haloperidol Haloperidol 1,5 mg Tab Dus 1

2

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
No. SP : 21/I/2017

Nama PBF : Apotek Kimia Farma 62
Alamat : Jalan Gajah Mada, 171 Jember
Telp : 0331-489020
Bentuk Sediaan dan Jumlah(angka&

No Nama Obat
Kekuatan/Potensi Kemasan huruf)
1 Tremenza Pseudoefedrin Tablet 400 Tablet
2
3
4
5

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
gung jawab
uda, Apt
29.114/IX/2016
No. SP : 21/I/2017

Nama PBF : Apotek Kimia Farma 121
Alamat : Jalan Letjen Suprapto, 71 Jember
Telp : 0331-321187
Bentuk Sediaan dan Jumlah(angka&

No Nama Obat
Kekuatan/Potensi Kemasan huruf)
1
2
3
4
5

No. Izin Sarana : 503.445/41/429.207/2016
Banyuwangi,

440/1774/SIPA/429.114/IX/2016
gung jawab
uda, Apt
29.114/IX/2016
No. SP : / /

Nama : Ditha Violy Nindyasari., S.Farm., Apt.
Nama PBF :
Alamat :
Telp :

Farmasi Sediaan
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Bina San Prima
Alamat : Jl. Letjend. Sutoyo No. 138 Jember
Telp : 0331-332928
1 ALLORIS TAB @ 100 (SANBE) Tablet Box 1

2 CEFAT 500MG CAP@100 Kapsul Box 1
3 EPEXOL DROP 20ML Botol Botol 3
4 EPEXOL SYR 120ML Botol Botol 4
5 EPISAN SUSP 100ML Botol Botol 3
6 FOLAVIT 400MCG TAB@100 Tablet Box 1
7 HISTAPAN 50MG TAB@100 Tablet Box 1
8 PUMPITOR KAPSUL Kapsul Box 1
9 SANMOL 125MG/5ML SYR 60 ML Botol Botol 10
10 SANMOL 500 MG TAB Tablet Box 1
11 SANMOL 60MG/0.6ML DROP 15 ML Botol Botol 6
12 TRICHODAZOL 500MG TAB@100 Tablet Box 1
13 ANTANGIN GINGERMINT 15 ML @12 Sachet Box 3
14 ANTANGIN JRG CAIR 15ML SACH@12 Sachet Box 3
15 ANTANGIN PERMEN HONEY MINT@5 Sachet Box 4
16 OB HERBAL SYR 100ML Botol Botol 3
17 FORBETES 500MG TAB@100 Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Anugrah Argon Medica
Alamat : Jl. Teuku Umar No. 72 Kebonsari Jember
Telp : 0331-326716
1 LEUKOMED T PLUS 7.2 X 5CM Pcs Pcs 1

2 LEUKOPLAST 1562 (2.5CMX1) Pcs Pcs 2
3 LEUKOPLAST 1621 (1.25CMX4.5) Pcs Pcs 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 CRAVIT 0.5% EYE DROP 5ML Botol Botol 2

2 FISHERMANS SF CITRUS 25GR Sachet Sachet 2
3 FOLAMIL GENIO SOFTCAP@30 Kapsul Box 2
4 INCIDAL OD 10MG CAP@50 Kapsul Box 1
5 NORELUT 5MG TAB@50 Tablet Box 1
6 TERRAMYCIN 1% EYE OINT 3.5GR Tube Tube 2
7 VOMETA 5MG/ML DROPS Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Enseval Putera Megatrading
Alamat : Jl. Wolter Monginsidi No. 889 Jember
Telp : 0331-335000
1 ENYSTIN DROPS Botol Botol 1

2 INTERZINC SYR 60ML Botol Botol 3
3 NEURALGIN RX KPL@100 Kapsul Box 1
4 PAMOL SYR Botol Botol 3
5 PEPTISOL 185GR DUS VANILA Pcs Box 1
6 PLANTACID SUSP FORTE 100ML Botol Botol 2
7 PLANTACID SUSP 100ML Botol Botol 2
8 TAMOFEN 10 MG TAB @ 30 Tablet Box 2
9 VENOSMIL 200MG CAP@20 Kapsul Box 1
10 ZOTER 400MG TAB@12 Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 ALOCLAIR GEL 8ML Tube Tube 2

2 DIGENTA CR 10GR Tube Tube 2
4 INTERHISTIN 50MG TAB@100 Tablet Box 1
5 NEUROTAM 1200MG TAB@50 Tablet Box 1
6 OTOPAIN EAR DROP 8ML Botol Botol 3
8 PEPTISOL 185GR DUS VANILA Pcs Pcs 1
9 PLANTACID FORTE TAB@100 Tablet Box 1
10 SALTICIN CR 5GR Tube Tube 6
11 THIAMYCIN 1000MG KPL@50 Kapsul Box 1
12 TAMOFEN 10 MG TAB @ 30 Tablet Box 2
13 VOMITAS SYR 60ML Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Antarmitra Sembada
Alamat : Jl. Imam Bonjol No. 63 Kaliwates Jember
Telp : 0331-428184
1 CLINDAMYCIN 300MG CAP@50 GNOV Kapsul Box 1

2 COOLING 5 SPRAY 1.4% COOLMINT Pcs Pcs 3
3 FEROSPAT TAB EFF Tablet Botol 2
4 KETOMED 2% SCALP LOT 60ML Botol Botol 2
5 MEDI-KLIN TR GEL 15GR Tube Tube 1
6 MICROLAX ENEMA 5ML@1 Tube Tube 4
7 OXOFERIN SOL TOP 30ML Botol Botol 4
8 PARASOL LOT 30 @ 120 ML Tube Tube 1
9 PUREBABY RASH CREAM 50GR Tube Tube 3
10 REFAQUIN CREAM Tube Tube 3
11 RYVEL DROP 10ML Botol Botol 2
12 RYVEL SYR 60ML Botol Botol 3
13 SCABIMITE 5% CR 10GR Tube Tube 4
15 SUTRA KLASIK KONDOM@12 Pcs Box 6
16 SUTRA PERKASA CAP@2 Pcs Box 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 BENZOLAC 2.5% GEL 5GR Tube Tube 3

2 BREATHY NASAL DROP Botol Botol 3
3 RAMIPRIL 10MG TAB@30 GNV Botol Botol 1
4 RAMIPRIL 5MG TAB@100 GNV Tube Tube 1
5 KLODERMA CR 5GR Tube Tube 2
7 ONDANSETRON 4MG TAB@12 GNV Tablet Box 1
8 POLYSILANE TAB@40 Tablet Box 1
9 PRORIS FORTE SYR 50ML Botol Botol 1
10 PRORIS SYR 60ML Botol Botol 2
11 PUREKIDS INHALANT 10ML Botol Botol 1
12 SARI KURMA AL-JAZIRA 360GR Botol Botol 1
13 SARUNG TANGAN SENSI (L) Pcs Box 1
14 SARUNG TANGAN SENSI (M) Pcs Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 CAPTOPRIL 50MG TAB@50 GHX Tablet Box 2


No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 ALOCLAIR GEL 8ML Pcs Pcs 1

2 CEFSPAN 100MG CAP@30 Kapsul Box 1
5 METRIX 2MG TAB@30 Tablet Box 1
8 ZOTER CR 5GR Tube Tube 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 DUREX EXTRA SAFE KONDOM@12 Pcs Box 1

2 DUREX FETHERLITE KONDOM@12 Pcs Box 4
3 DUREX PERFORMA KONDOM@12 Pcs Botol 1
4 DUREX PLAY 100ML Tube Botol 1
5 DUREX PLAY VIBRATIONS RING 1 Pcs Botol 2
6 CERINI SYR 60ML Botol Box 1
7 MEFINAL 500MG KPL@100 Kapsul Box 1
8 SANMOL 60MG/0.6ML DROP 15 ML Botol Box 1
9 SANPRIMA SYR 60ML Botol Botol 2
11 ANTANGIN JRG CAIR 15ML SACH@12 Sachet Botol 1
12 ANTANGIN PERMEN HONEY MINT@5 Pcs Box 1
14 OB HERBAL ZIPLONG SC@5 Sachet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 STREPSIL REG@ 12 Sachet Box 12

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Kimia Farma Trading & Dist.
Alamat : Jl. Dr. Soebandi No. 60 Jember
Telp : 0331-421675
1 CHANNA PLUS 10GR Sachet Box 10

2 AMLODIPINE 10 MG-STRIP 5X10 TA Tablet Box 4
3 ALLOPURINOL 100 MG-STRIP 10X10 Tablet Box 4
4 CIMETIDINE 200MG TAB@100 GKF Tablet Box 1
5 GLIBENCLAMIDE 5 MG TABLET Tablet Box 4
6 BETASON KRIM Tube Box 1
7 DEXOCORT 0.25 % CREAM Tube Box 1
8 SALICYL FRESH 60GR KEMASAN BAR Botol Botol 36
9 CENDO ASTHENOF 5 ML Botol Botol 3
10 CENDO LYTEERS EYE DROPS 15 ML Botol Botol 2
11 ASPILET CHEWABLE @ 100 TAB Tablet Box 1
12 IMBOOST FORCE TAB Tablet Box 1
13 BISOLVON FLU & BATUK SYR I 60M Botol Botol 6

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
xc

Telp : 0331-421675
1 MAGASIDA SUSP 120ML Botol Botol 36

2 MAGASIDA TAB@100 Tablet Box 4
3 ENKASARI LIQ 120ML Botol Botol 25
4 FITOCARE M KAYU PUTIH 50 ML Botol Botol 24
6 MARCKS MOISTURIZER 30GR Pcs Pcs 12
7 VENUS CLEANSING GEL - OILY SKIN 60 ml Pcs Pcs 6
8 VENUS CLEANSING GEL - OILY SKIN 100 ml Pcs Pcs 6
9 VENUS F.TONER NORMAL& DRY 50 Pcs Pcs 6
10 VENUS FACE TONER - NORMAL SKIN Pcs Pcs 6
12 VENUS FACE TONER - OILY SKIN 1 Pcs Pcs 6
13 VENUS FACIAL WASH 50ml Pcs Pcs 12
14 MARCKS BEDAK CREME Pcs Pcs 12
15 MARCKS TEENS CP INVISIBLE Pcs Pcs 12
16 MARCKS TEENS CP PINK Pcs Pcs 12

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

3 COOLING 5 SPRAY 1.4% COOLMINT Botol Botol 1
6 LANSOPRAZOLE KAPS @ 20 ( GNV ) Kapsul Box 2
8 MEDIKLIN GEL Tube Tube 1
9 OMEPRAZOLE 20MG CAP@30 GNOV Kapsul Box 1
10 OMEPROS CAP@30 Kapsul Box 1
12 POLYSILANE TAB@40 Tablet Box 2
13 PRAXION SYR 60ML JERUK Botol Botol 1
15 PUREKIDS INHALANT 10ML Pcs Pcs 4
19 SARUNG TANGAN SENSI (L) Pcs Box 1
20 SARUNG TANGAN SENSI (M) Pcs Box 1
23 SENSIPAD ALAS POPOK L@10 Pcs Pcs 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Kebayoran
Alamat : Jl. Nusantara V/12A blok C Jember
Telp :
1 INPEPSA SYRUP 100 ML Botol Botol 1

2
3
4
5

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-487380
1 FUNGIDERM 10 GRAM Tube Tube 4

2 JESSCOOL HANGER TAB EFF@20 Botol Botol 1
3 JESSCOOL TAB EFF@ 6 Botol Botol 1
4 TERMOREX SYRUP 60 ml Tablet Botol 1
5 TERMOREX SYRUP 30 ml Botol Botol 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-487380
1 BRAITO 0.5% EYE DROP 5ML ORIG Botol Botol 12

2 KONVERMEX 125MG TAB@100 Tablet Box 1
3 KONVERMEX 125MG/5ML SUSP 10ML Botol Botol 15
4 KONVERMEX 250MG TAB@50 Tablet Box 2
6 EVER E 250 CAP AMPLOP@6 Kapsul Box 1
7 PARAMEX TAB@200 Tablet Box 1
8 SILADEX M & E SYR 30ML Botol Botol 10
10 SILADEX ANTITUSSIVE SYR 30ML Botol Botol 5
12 VIGEL GEL 30GR Tube Tube 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-421675
1 ALERGINE 10 MG TABLET SALUT SE Tablet Box 1

4 ANTALGIN 500 MG TAB Tablet Box 2
5 ANTIHEMOROID SUPP Supp Box 1
6 AUTOCHECK CHOLESTEROL STR@10 Strip Box 1
7 BATUGIN ELIXIR -BT 120 ML Botol Botol 3
8 BEDAK SALICYL 2% 60 gr Botol Botol 50
9 BETADINE OBAT KUMUR 190 ML Botol Botol 2
10 BETASON N KRIM Tube Tube 11
11 CAPTOPRIL 25 MG-STRIP 10X10 TA Tablet Box 1
13 CENDO CENFRESH EYE DROP 5 ML Botol Botol 1
15 DEXAMETHASONE 0.5 MG-BT 100 TA Tablet Box 1
16 DEXOCORT 0.25 % CREAM Tube Tube 28
17 DOXEF 125 MG/ML SIRUP KERING Botol Botol 2
18 ENKASARI CAIRAN-BT 120 ML Botol Botol 9
21 FITUNO BLISTER@30 Tablet Box 20
22 FUNGORAL 2% KRIM 10 GRAM Tube Tube 12
23 FUNGORAL 200 MG-STRIP 5X10 TAB Tablet Box 1
24 GENTAMYCIN 0,1 % SALEP KULIT Tube Tube 11
25 HYDROCORTISONE 2,5% KRIM Tube Tube 3
26 KASA HYDR STERIL 16/16 KH Box Box 12
27 KIMOXIL 500 MG CAPS Kapsul Box 1
28 KLOTAREN 25 MG TABLET SALUT EN Tablet Box 1
29 MAGASIDA 120 ML SUSPENSI Botol Botol 14
31 MARCKS BEDAK CREME 20gr Pcs Pcs 1
32 MARCKS BEDAK ROSE Pcs Pcs 4
33 MARCKS VENUS CLEANSING MILK100 Pcs Pcs 1
34 NEUROVIT E TABLET SALUT GULA Tablet Box 1
35 NITROKAF RETARD KAPSUL (100) Kapsul Box 1
36 PIROXICAM 20 MG-STRIP 10X10 TA Tablet Box 1
37 RANITIDIN 150 MG-STRIP 3X10 TA Tablet Box 3
38 SALICYL FRESH Botol Botol 23
39 TOPGESIC 500 MG TABLET SALUT S Tablet Box 9
40 VENUS CLEANSING GEL - OILY SKI Pcs Pcs 12
42 VENUS CLEANSING MILK - NORMAL Pcs Pcs 1
46 VENUS LP DYNAMIC NO.2 NAT.BEI Pcs Pcs 8
47 VENUS LP DYNAMIC NO.3 IVORY Pcs Pcs 13
48 VENUS REFILL TWC NO.1 TRANSLUC Pcs Pcs 2
49 VENUS TWC NO.1 TRANSLUCENT Pcs Pcs 9
50 VENUS TWC NO.2 NATURAL Pcs Pcs 9
51 VENUS TWC NO.3 PORCELEIN Pcs Pcs 11
52 YOU C-1000 LEMON Botol Botol 8
53 YOU C-1000 ORANGE Botol Botol 6
54 YOU-C 1000 ORANGE WATER Botol Botol 4

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 ROHTO COOL Botol Botol 6

2
3
4
5

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000

2 ALOCLAIR PLUS SPRAY Pcs Pcs 1
3 CEFADROXIL 500MG CAP@50 GHX Kapsul Box 1
4 COPAL CHEST RUB 25GR Pcs Pcs 2
5 ENTRASOL ACTIVE MOCHACCINO 160 Pcs Pcs 1
6 ENTRASOL GOLD 185GR VANILA Pcs Pcs 2
8 FORNEURO CAP@30 Kapsul Box 1
9 INERSON 0.25% OINT 15GR Tube Tube 1
10 KALPANAX K CREAM 5 GRAM Tube Tube 3
11 KALPANAX TINCT 10ML Botol Botol 8
13 NEPHRISOL SACH 185GR VANILA Pcs Pcs 1
18 PRENAGEN ESENSIS 180GR COKLAT Pcs Pcs 1
19 PRENAGEN MOMMY STRAWBERRY 200G Pcs Pcs 2
20 PROMAG SUSPENSI 7ML SACH@6 Sachet Box 3
21 PROMAG TAB Tablet Box 3
22 WOODS COUGH EXP SYR 100ML Botol Botol 2
24 WOODS COUGH SYR ANTITUSIF Botol Botol 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 KANDISTATIN DROP(METISKA) Tablet Box 1

2 NYSTIN DROP 12ML Kapsul Box 1
3 AKURAT TES HAMIL@25 Botol Botol 7
4 SENSITIF Botol Botol 1
5 L-BIO SACH@30 Tablet Box 1
AKURAT TES HAMIL@25 2

AMADIAB 4MG TAB@50 1
APIALYS DROP 10ML 2
APIALYS SYR 100 ML
CLINMAS 300MG CAP@30 1
EYEVIT TAB@30 1
KANDISTATIN DROP(METISKA)
LAMESON 4MG TAB@100
L-BIO SACH@30 1
LAPIFED DM SYR 100ML 1
LASAL EXP SYR 100ML 1
MUCOS 15MG/5ML SYR 60ML 1
NUCRAL SUSP 100 ML(GDN) 1
NYSTIN DROP 12ML
OPTALVIT PLUS TAB@30 4
POLYSILANE SUSP 100ML 4
PROFEN SIRUP 60 ML (GDN) 1
SENSITIF 1
SENSITIF COMPACT PACK 1
SENSITIF UC STRIP 3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 AVAMYS 120 NASAL SPRAY Pcs Pcs 1

2 DIANE 35 TAB@21 Tablet Box 3
4 NEEDLE NOVOFINE 32G Pcs Box 2
5 HYPAFIX 5CM X 1 M Pcs Pcs 3
6 KETRICIN 0.1% ORABASE 5GR Tube Tube 4
9 LEUKOPLAST 1622.02 (1 X 5) Pcs Pcs 4
10 LEUKOPLAST 1622.03H(1 X 5) Pcs Pcs 9
11 LIPITOR 10MG TAB@30 Tablet Box 2
12 LIPITOR 20 MG TABLET@30 Tablet Box 2
14 NEEDLE NOVOFINE 30G TRM Pcs Box 2
15 GOLDEN GINGER CAN CLASSIC HOT Pcs Pcs 2
16 GOLDEN GINGER CAN JAHE SUSU150 Pcs Pcs 4
17 GOLDEN GINGER CAN KOPI JAHE150 Pcs Pcs 1
18 GOLDEN GINGER CAN MILD 150GR Pcs Pcs 4
19 SUPER ESTER C HOLISTICARE@30 Tablet Box 4
20 TEOSAL TAB@100 Tablet Box 1
21 VECTRINE 300MG CAP@20 Kapsul Box 1
Obat tersebut akan digunakan untuk memenuhi: Apotek Kimia Farma Genteng
Nama Sarana : JL Diponegoro No. 07 Genteng Banyuwangi
Alamat Lengkap : 503.445/26/429.113/2017
No. Izin Sarana
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Alamat : Jalan Kenjeran No. 561 A Surabaya
Telp : 031-3821110
1 ZYLORIC 100MG TAB@200 Botol Botol 2

2 ZYLORIC 300MG TAB@100 Sachet Sachet 2
3 BABY COUGH SYR 60ML Kapsul Box 2
4 MYLANTA TAB @ 100 Kapsul Box 1
5 MYLANTA SYRUP 50 ML Tablet Box 1
6 MYLANTA SYRUP 150 ML Tube Tube 2
DEXTEEM PLUS TAB@100
MOLACORT 0.5MG TAB@100
7 Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Alamat : Jl. Berbek industri I No.1 Kav A-C Waru Sidoarjo
Telp : 031-8439839
1 HARNAL D 0.2MG CAP@28 Kapsul Box 1

2 EMTRIX 10ML Tube Tube 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 SENSIPAD ALAS POPOK L@10 Pcs Pcs 6

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 POLYSILANE SUSP 100ML Botol Botol 10

3 KETOMED 2% CR 15GR Tube Tube 2
5 FIESTA EXTREME CONDOM@3 Pcs Pcs 2
6 FIESTA MAX DITTED@ 3 Pcs Pcs 2
7 FIESTA NEON@3 Pcs Pcs 1
8 FIESTA LUBRICANT GEL 70ML Botol Botol 1
9 FIESTA LUBRICANT GEL STRAW 70M Botol Botol 1
12 PRAXION DROP 15ML Botol Botol 4
15 COOLING 5 SPRAY 1.4% CHERRY Botol Botol 5
17 SUTRA KLASIK KONDOM@ 3 Pcs Pcs 7
18 SUTRA OK KONDOM@ 3 Pcs Pcs 13

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
Bentuk
No Nama Obat Bentuk Sediaan Jumlah
Sediaan
1 ALBOTHYL SOL CONC 5ML Botol Botol 4

4 FIESTA DOTTED KONDOM@ 3 Pcs Pcs 1
5 FIESTA LUBRICANT GEL 70ML Pcs Pcs 2
6 FIESTA LUBRICANT GEL STRAW 70M Pcs Pcs 2
9 LACTO - B 1 gr Sachet Box 1
11 MAXIMUS 500/45MG CAP@30 Kapsul Box 3
14 MELANOX CR 15GR Tube Tube 1
16 NEBACETIN PWD 5GR Pcs Pcs 4
18 OMEPROS CAP@30 Kapsul Box 2
20 PHAROLIT 5.8GR SACH@60 Sachet Box 1
27 SAFE CARE AROMATHERAPY ROLL ON Botol Botol 7
30 SUTRA KLASIK KONDOM@ 3 Pcs Box 1
31 SUTRA OK KONDOM@ 3 Pcs Box 1
32 VITAQUIN CR 15GR Tube Tube 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 AVAMYS 120 NASAL SPRAY Pcs Box 4

2 BISOLVON EXTRA SYR 125ML Botol Botol 1
3 BISOLVON EXTRA SYR 60 ML Botol Botol 2
5 CELESTAMINE SYR 60ML Botol Botol 2
6 DULCOLAX 5 MG ECT @200 TAB Tablet Box 3
7 ILIADIN 0.025% NASAL DROP 10ML Botol Botol 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :

2 LACTULAX SYR 60ML Botol Botol 2
3 RENADINAC 50MG TAB@100 Tablet Box 1
4 ROHTO COOL Pcs Pcs 11

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 SAGESTAM EYE DROP 5ML DOSP Botol Botol 5

2 BIOTHICOL FORTE SYR 60ML Botol Botol 1
3 CEFAT SYR 60ML Botol Botol 1
4 CERINI SYR 60ML Botol Botol 3
5 CLANEKSI FORTE SYR 60ML Botol Botol 1
6 FORMYCO CR 10GR Tube Tube 5
7 LODIA FILM-COATED TAB Tablet Box 1
13 ANTANGIN JRG TAB@80 Tablet Box 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : Parit Padang Global
Alamat : Jl Teuku Umar 68
Telp : 0331-333318
1 ADEM SARI CHINGKU 320ML Botol Botol 20

2 ASEPSO PLUS SOAP 80GR ORIGINAL Pcs Pcs 5
3 ASEPSO SULPHUR 80GR Pcs Pcs 1
4 BETADINE FEMININE HYGIENE 60 M Pcs Pcs 2
5 BETADINE OINT 10 GRAM Tube Tube 1
6 COUNTERPAIN CR 15GR Tube Tube 3
8 CP GROW BLACKCURRANT 200 ML Botol Botol 1
9 CURCUMA + GROW ORANGE 200ML Botol Botol 1
10 CURCUMA + GROW STRAWBRY 200ML Botol Botol 4
11 DIAPET ANAK SACH@6 Sachet Sachet 1
12 DRAMAMINE 50MG TAB@100 Tablet Box 1
13 ELLGY PLUS CRACKED HEEL CR 10G Tube Tube 3
14 FITKOM GUMMY CALCIUM SACH@4 Sachet Box 1
15 FITKOM GUMMY FIBER@5 Pcs Box 2
16 FITKOM GUMMY FRUIT&VEGGIE@5 Pcs Box 11
17 FITKOM GUMMY GO !! SACH@5 Pcs Box 2
18 FITKOM GUMMY OMEGA@5 Pcs Box 2
19 FITKOM GUMMY VIT C& ZINC Pcs Box 2
20 FITKOM TAB@30 ORANGE Tablet Botol 4
21 FITKOM TAB@30 STRAW Tablet Botol 2
22 IMBOOST FORCE ES CPL@30 Kapsul Box 1
23 IMBOOST SYRUP 120 ML Botol Botol 4
24 KENALOG IN ORABASE 5GR Tube Tube 4
25 PHISOHEX 110 ML Botol Botol 1
26 PRIMOLUT N 5MG TAB@30 Tablet Box 1
27 TEMPRA DROPS 15 ML Botol Botol 6
28 TEMPRA SYR 60ML Botol Botol 6
29 VEGETA HERBAL ANGGUR 5GR SAC@6 Sachet Sachet 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 DUREX PLAY VIBRATIONS RING 1 Pcs Pcs 4

2 DUREX COMFORT KONDOM@12 Pcs Pcs 1
3 ANTANGIN JUNIOR SACHET@5 Sachet Box 7
5 OB HERBAL ZIPLONG SC@5 Sachet Box 1
7 ANTANGIN PERMEN HONEY MINT@5 Sachet Box 4
9 SAGESTAM CR 10GR Tube Tube 4
13 OCUSON TAB@100 Tablet Box 1
14 BAQUINOR 500MG KPL@20 Kapsul Box 1
15 PIROFEL 10MG CAP@100 Kapsul Box 1
19 FORUMEN EAR DROP Botol Botol 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 ACRAN 150MG TAB@30 Pcs Box 1

2 DETTOL ANTISEPTIC LIQ 100 ML Pcs Box 4
3 DETTOL ANTISEPTIC LIQ 250 ML Pcs Botol 5
4 DETTOL ANTISEPTIC LIQ 50 ML Tube Botol 3
5 DUREX PLAY 100ML Pcs Botol 4
6 DUREX PLAY 50ML Botol Box 5
7 DUREX PLAY VIBRATIONS RING 1 Kapsul Box 1
8 KY JELLY PERSONAL 100GR Botol Box 3
9 KY JELLY PERSONAL 50GR Botol Botol 4

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 FLUMETHOLON EYE DROP 5ML Botol Botol 1

5 GOLDEN GINGER CAN MILD 150GR Pcs Pcs 6
6 KARY UNI EYE DROP 5ML Botol Botol 3
7 CANDERIN 8MG TAB@30 Tablet Box 1
8 FISHERMANS ANISEED 25GR Pcs Pcs 12
9 FISHERMANS ORIGINAL 25GR Pcs Pcs 11
10 FISHERMANS SF CITRUS 25GR Pcs Pcs 12
11 FISHERMANS SF LEMON 25GR Pcs Pcs 12
12 FISHERMANS STRONG MINT 25GR Pcs Pcs 12

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 NEEDLE NOVOFINE 32G Pcs Box 2

7 HYPAFIX 5 CM X 5 M Pcs Pcs 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
Bentuk
Sediaan

2 COOLING 5 SPRAY 1.4% COOLMINT Tube Tube 20
3 TISSUE SUPER MAGIC MAN Botol Botol 24

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 SALTICIN CR 5GR Tube Box 6

2 SAN-B-PLEX DROP 15ML Botol Botol 2
3 BECOM C KPL@100 Kapsul Box 2
5 SANMAG SUSP 120ML Botol Botol 4
6 NEO KAOLANA SUSP 120ML Botol Botol 6
10 MEFINAL 500MG KPL@100 Botol Botol 3
11 DETTOL BODY W LAST 300 FRESH Botol Botol 3
12 DETTOL BODY W COOL 300ML BTL Botol Botol 3
13 DETTOL BODY W FRESH 300ML BTL Botol Botol 3
14 DETTOL BODY W ORIG 300ML BTL Botol Botol 3
15 DETTOL BODY W SENS 300ML BTL Botol Botol 3
16 DETTOL IHS ORIG 50 ML Botol Botol 6
17 DETTOL HIS SOOTHE 50 ML Botol Botol 3
18 DETTOL ANTISEPTIC LIQ 100 ML Botol Botol 5
20 DUREX TOGETHER KONDOM@12 Pcs Box 4
21 DUREX FETHERLITE KONDOM@ 3 Pcs Box 6
22 DUREX STRAW KONDOM@ 3 Pcs Box 4
23 DUREX EXTRA SAFE KONDOM@ 3 Pcs Box 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :

2
3
4
5

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000

3 KALPANAX TINCT 10ML Pcs Pcs 20
4 THROMBOPHOB GEL (NORDMARK) Tube Tube 6
5 THROMBOPHOB OINT 15GR Tube Tube 6
6 ENTRASOL GOLD 185GR COKLAT Pcs Pcs 3
7 ENTRASOL GOLD 185GR PLAIN Pcs Pcs 2
9 ENTRASOL GOLD 2X185GR PLAIN Pcs Pcs 4
10 ENTRASOL GOLD 2X185GR VANILA Pcs Pcs 1
11 ENTRASOL GOLD 2X185GR COKLAT Pcs Pcs 1
12 ENTRASOL ACTIVE VANILA LATE160 Pcs Pcs 2
13 NEPHRISOL SACH 185GR VANILA Pcs Pcs 4
14 NEPHRISOL SACH 185GR COKLAT Pcs Pcs 4
15 SAKATONIK LIVER KPL@100 Kapsul Box 1
16 SAKATONIK LIVER SYR 310ML Botol Botol 6
19 PAMOL DROP 15ML Botol Botol 6
20 PAMOL FORTE TAB@60 Tablet Box 1
21 PAMOL 500MG TAB@100 Tablet Box 1
22 PLANTACID TAB@60 Tablet Box 1
27 VENOSMIL 200MG CAP@20 Kapsul Box 1
30 ALOCLAIR ORAL RINSE 60ML Pcs Pcs 2
33 PROMAG DOUBLE ACTION TAB@12 Tablet Box 2
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

3 VEGEBLEND 18 JR CAP@30 Kapsul Box 4
4 VEGEBLEND 21 JR CAP@30 Kapsul Box 4
5 FRUIT 18 ADULT TAB@30 Tablet Box 2
6 FRUIT 18 JR TAB@30 Tablet Box 2
9 PRAXION FORTE SYR 60ML JERUK Botol Botol 3
12 PRORIS 200MG TAB@50 Tablet Box 4
16 SUTRA OK KONDOM@12 Pcs Box 8
17 SUTRA RM KONDOM@12 Pcs Box 4
18 REGROU FORTE SOL 30ML Pcs Botol 4
19 BENZOLAC-CL GEL 5GR Tube Tube 5
20 MEDIQUIN CR 15GR Tube Tube 3
21 MEDSCAB CR 30GR Tube Tube 2
22 VITACID 0.025% CR 15GR Tube Tube 2
23 VITACID 0.025% GEL 20GR Tube Tube 1
26 MELANOX FORTE CR 15GR Tube Tube 1
27 PIROTOP 2% CR 10GR Tube Tube 3
28 PIROTOP OINT 10GR Tube Tube 3
30 SKRINEER GIRLY MASKER@5 Pcs Pcs 20
31 SKRINEER HIJAB@5 Pcs Pcs 20
32 SKRINEER MASKER MULTI FUNGSI@5 Pcs Pcs 20
33 SKRINER MASKER MULTI FUNGSI@10 Pcs Pcs 20

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-421675
1 ALERGINE 10 MG TABLET SALUT SE Tablet Box 15
5 AUTOCHECK CHOLESTEROL STR@10 Strip Box 12
7 BETADINE SOLUTION 30 ML Botol Botol 15
11 BETASON N KRIM Tube Box 1
14 CAPTOPRIL 12.5 MG-STRIP 10X10 TA Tablet Box 3
16 CENDO CENFRESH EYE DROP 5 ML Botol Botol 6
17 CENDO XITROL EYE DROPS 5 ML Botol Botol 8
18 DEXAMETHASONE 0.5 MG-BT 100 TA Tablet Box 2
19 DEXOCORT 0.25 % CREAM Tube Box 2
21 FITOCARE M KAYU PUTIH 30 ML Botol Box 1
23 FITUNO BLISTER@30 Tablet Box 20
24 FUNGORAL 2% KRIM 10 GRAM Tube Box 1
26 HYDROCORTISONE 2,5% KRIM Tube Box 1
27 KASA HYDR STERIL 16/16 KH Box Box 12
28 KIMOXIL 500 MG CAPS Kapsul Box 1
31 PARACETAMOL 500 MG 100 TAB STR Tablet Box 10
32 PIROXICAM 20 MG-STRIP 10X10 TA Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-487380

2 JESSCOOL HANGER TAB EFF@20 Botol Botol 1
3 JESSCOOL TAB EFF@ 6 Botol Botol 1
4 TERMOREX SYRUP 60 ml Tablet Botol 1
5 TERMOREX SYRUP 30 ml Botol Botol 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 KANDISTATIN DROP(METISKA) Botol Botol 12

2 NYSTIN DROP 12ML Botol Botol 6
3 AKURAT TES HAMIL@25 Strip Box 1
4 SENSITIF UC STRIP Strip Box 1
5 L-BIO SACH@30 Sachet Box 1
6 SENSITIF COMPACT PACK Pcs Pcs 1
7 APIALYS DROP 10ML Botol Botol 2
8 APIALYS SYR 100 ML Botol Botol 2
9 EYEVIT TAB@30 Tablet Box 1
10 SIRPLUS SYR 100ML ANGGUR Botol Botol 4
11 SIRPLUS SYR 100ML JERUK Botol Botol 6
12 SIRPLUS SYR 100ML STRAWBERI Botol Botol 6
13 MUCOS 15MG/5ML SYR 60ML Botol Botol 5

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 CATAFLAM 50MG TAB@50 Tablet Box 4

2 POLIDENT ADHESIVE 15GR Tube Tube 6
4 NEW DIATAB TAB Tablet Box 1
5 SUMAGESIC 600 MG TAB @ 100 (UN Tablet Box 1
6 BIOGESIC BLISTER 100 S (UN) Tablet Box 1
7 VICKS FORMULA 44 ADULT 100 ML Botol Botol 8
9 VICKS FORMULA 44 ANAK 27 ML ST Botol Botol 10
10 VICKS VAPORUB 10 GM Pcs Pcs 15
12 PANADOL EXTRA @ 100 TAB Tablet Box 1
13 DULCOLACTOL SYR 60 ML Botol Botol 10
15 NEUROBION TAB Tablet Box 1
16 NATUR-E NR CAP 300 IU@16 Kapsul Box 5
17 NATUR-E NR CAP 300IU@32 Kapsul Box 5
18 SANGOBION KAPSUL @ 250 Kapsul Box 2
19 SANGOBION SYR 100ML Botol Botol 5
20 SANGOBION FEMINE CAP@120 Kapsul Box 1
21 SANGOBION DROP 15ML Botol Botol 2
22 ENERVON C FC TAB @ 100 (UN) Tablet Box 1
23 REDOXON ZINC EFF@10 ORANGE Botol Botol 4
24 TONIKUM 100 ML SYR (NEW) Botol Botol 4
25 SCOTTS EMULSION ORIG 200ML Botol Botol 4
26 SCOTTS EMULSION ORIGINAL 400 M Botol Botol 2
27 SCOTT EMULSION VITA 400 ML Botol Botol 5
28 BEPANTHEN OINT @ 20 GR (BAYER) Tube Tube 10
29 TRANSPULMIN BB BALSAM 10GR Tube Tube 10
31 INSTO MOIST 7.5 ML Botol Botol 12
33 BISOLVON KIDS 4MG/5ML SYR 60 M Botol Botol 6
34 BISOLVON ELIX I 125ML Botol Botol 10
35 BISOLVON ELIX I 125ML Botol Botol 10
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017
o

Telp : 031-3821110
1 ZYLORIC 100MG TAB@200 Botol Botol 2

2 ZYLORIC 300MG TAB@100 Sachet Sachet 2
3 BABY COUGH SYR 60ML Kapsul Box 2
4 MYLANTA TAB @ 100 Kapsul Box 1
5 MYLANTA SYRUP 50 ML Tablet Box 1
6 MYLANTA SYRUP 150 ML Tube Tube 2
DEXTEEM PLUS TAB@100
7 Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Alamat : Jalan KH Sidik No. 110 No. Jember
Telp : 0331-482332

4 BETADINE FEMININE HYGIENE 60 M Pcs Pcs 2
8 CP GROW BLACKCURRANT 200 ML Botol Botol 1
9 CURCUMA + GROW ORANGE 200ML Botol Botol 1
11 DIAPET ANAK SACH@6 Sachet Sachet 1
13 ELLGY PLUS CRACKED HEEL CR 10G Tube Tube 3
15 FITKOM GUMMY FIBER@5 Pcs Box 2
16 FITKOM GUMMY FRUIT&VEGGIE@5 Pcs Box 11
17 FITKOM GUMMY GO !! SACH@5 Pcs Box 2
18 FITKOM GUMMY OMEGA@5 Pcs Box 2
19 FITKOM GUMMY VIT C& ZINC Pcs Box 2
20 FITKOM TAB@30 ORANGE Tablet Botol 4
21 FITKOM TAB@30 STRAW Tablet Botol 2
29 VEGETA HERBAL ANGGUR 5GR SAC@6 Sachet Sachet 2
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
3 DRAMASINE TAB@100 Tablet Box 4
4 CARDIO ASPIRIN 100MG TAB@30 Tablet Box 2
5 NIZORAL 2% CR 5GR Tube Tube 8
6 MICROGYNON LIBI@ 10 Tablet Box 6
11 COUNTERPAIN COOL 5GR Tube Tube 6
12 COUNTERPAIN COOL 15 GRAM Tube Tube 6
15 COUNTERPAIN PATCH HOT@5 Pcs Box 2
16 COUNTERPAIN PATCH@5 Pcs Box 1
17 IMBOOST TAB@50 Tablet Box 2
20 IMBOOST 1000 EFF TAB@10 Tablet Box 2
22 FITKOM TAB GRAPE@21 Tablet Botol 8
23 FITKOM TAB ORANGE@21 Tablet Botol 8
24 FITKOM TAB STRAWBERRY@21 Tablet Botol 10
26 TEMPRA SYR 30ML ANGGUR Botol Botol 8
27 VEGETA HERBAL ANGGUR 5GR SAC@6 Sachet Box 6
30 DIAPET ANAK SACH@6 Sachet Box 3
32 FITKOM GUMMY FRUIT&VEG SAC@10 Sachet Box 3
33 FITKOM GUMMY GO !! SACH@5 Sachet Box 5
34 FITKOM GUMMY OMEGA@5 Sachet Box 5
35 FITKOM GUMMY VIT C& ZINC Sachet Box 5
36 FITKOM GUMMY FIBER@5 Sachet Box 5
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
Bentuk
Sediaan

2 VOSTRIN SYR 60ML Botol Botol 1
3 ZAMEL DROP 16ML Botol Botol 3
4 EGOJI ANGGUR 100ML Botol Botol 6
5 EGOJI APPLEBERRY 100ML Botol Botol 6

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF :
Alamat :
Telp :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : / /

Nama PBF :
Alamat :
Telp :

Farmasi Sediaan
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : / /

Telp : 031-8439839
Farmasi Sediaan
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

3 CETIRIZINE 10MG TAB@30 GNOV Tablet Box 3
4 CLINOVIR 200MG TAB@30 Tablet Box 1
5 CLINOVIR 400MG TAB@30 Tube Tube 1
6 CLINOVIR 5% CR 5GR Tube Tube 3
15 PRORIS CHEW TAB@20 Tablet Box 5
18 PUREBABY CLEANS DIAPER CR 100G Tube Tube 3
19 PUREBABY LOT 80ML Botol Botol 1
21 PUREBABY SOOTHING CR 100GR Tube Tube 2
23 PUREKIDZ ITCHY CREAM 10GR Tube Tube 2
24 REGROU FORTE SOL 30ML Botol Botol 2
25 SARI KURMA AL-JAZIRA 330ML Botol Botol 8

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 ENSURE VAN 400GR Pcs Pcs 2

2 FLUMETHOLON EYE DROP 5ML Botol Botol 5
11 STIMUNO SYR 100ML GRAPE Botol Botol 10
12 STIMUNO SYR 60ML GRAPE Botol Botol 10
13 STIMUNO SYR 100ML TUTY FRUITY Botol Botol 4
14 STIMUNO SYR 60ML TUTY FRUITY Botol Botol 5
15 SUPER ESTER C BLISTER TAB@60 Tablet Box 2
19 VOMETA FLASH TAB@50 Tablet Box 2
20 VOMETA 1MG/ML SYR Botol Botol 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716


No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF :
Alamat :
Telp :
1 TIMBANGAN BADAN ONEMED Pcs Pcs 2

2 ONEMED KOTAK P3 K+ ISI
3 ONEMED KOTAK P3 K AA CARTON/12
4 TEST KEHAMILAN STRIP ONEMED
5 ONEMED RIVANOL 0.1% 100ML
6 ONEMED RIVANOL 0.1% 300ML
7 ONEMED ALKOHOL SWABS @100
8 KURSI RODA spirit
9 KURSI RODA 3 IN 1 (BAB,BARING)
10
11
12
13
14
15
16
17
18
19
20

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 AMOXSAN 500MG CAP@100 Kapsul Box 1

4 BLESIFEN TAB@20 Tablet Box 1
10 HISTAPAN 50MG TAB@100 Tablet Box 1
12 OCUSON TAB@100 Tablet Box 1
14 SANMOL 60MG/0,6ML DROP 15 ML Botol Botol 8

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 AMOXSAN SYRUP 60 ML Botol Botol 10

2 AMOXSAN 250MG/5ML SYR 60ML Botol Botol 4
3 CEFAT FORTE SYR 60ML Botol Botol 2
5 CLANEKSI SYR 60ML Botol Botol 2
7 BIOTHICOL SYR 60ML Botol Botol 2
8 BIOTHICOL FORTE SYR 60ML Botol Botol 2
9 ERYSANBE SYR 60ML Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
1 ANDALAN LAKTASI TAB@30 Tablet Box 1

2 ANDALAN PIL KB Tablet Box 1
7 FITKOM GUMMY FRUIT&VEGGIE@5 Sachet Box 5
13 IMBOOST FORCE SYR 120ML Botol Botol 6
14 IMBOOST FORCE SYRUP 60 ML Botol Botol 3
17 MICROGYNON LIBI@ 25 Tablet Box 5
18 MYCOSTATIN ORAL SUSP 12ML Botol Botol 6
22 VEGETA PACK @6 ORANGE Sachet Box 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :

2 SENSITIF UC STRIP Strip Box 2
5 PROFEN SIRUP 60 ML (GDN) Botol Botol 3
6 RHELAFEN SUSP 60ML Botol Botol 2
7 RHELAFEN FORTE SUSP 60ML Botol Botol 2
8 VENARON CAP CATCH COVER@20 Kapsul Box 1
9 APIALYS DROP 10ML Botol Botol 5
10 PEDIMIN DROP 15ML Botol Botol 3
11 EYEVIT SYR 60ML Botol Botol 6
12 EYEVIT TAB@30 Tablet Box 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 ANADIUM KAPL @ 30 (GDN) Strip Box 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT. Merapi Utama
Alamat :
Telp :
1 SALONPAS GEL 30GR Tube Tube 3

2 SALONPAS KOYO@12 Pcs Box 2
3 SALONPAS KOYO HOT @12 Pcs Box 2
4 ZORALIN CR 10GR Tube Tube 4
5 CINDALA GEL 10GR Tube Tube 4

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-487380
1 BRAITO 0.5% EYE DROP 5ML ORIG Botol Botol 24

2 BRAITO TEARS EYE DROP 5ML Botol Botol 12
6 TERMOREX DROP Botol Botol 6
7 TERMOREX PLUS SYR 60ML Botol Botol 8
8 TERMOREX PLUS SYR@30 ML Botol Botol 8
9 TERMOREX SYRUP 30ML Botol Botol 8
11 HEXOS BARLEY MINT Pcs Pcs 12
12 HEXOS LEMON MINT Pcs Pcs 12
13 HEXOS MINT Pcs Pcs 12
14 PARAMEX TAB@200 Tablet Box 1
15 RENOVIT KPL@30 Kapsul Box 2
16 RENOVIT KPL@ 4 Kapsul Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Sejahtera Surya Intrio
Alamat : Jalan Ngagel Jaya Utama 106 Surabaya
Telp : 031-5014086
1 BERSIH DARAH KEMBANG BULAN Tablet Box 12

2 BODREX EXTRA KPL@100 Kapsul Box 1
3 BODREX FLU & BATUK Tablet Box 1
4 BODREX FLU & BTK DAHAK TAB@100 Tablet Box 1
5 BODREX MIGRA Tablet Box 1
6 DEXTAMINE TAB@300 Tablet Box 1
7 DEXTEEM PLUS TAB@100 Tablet Box 1
8 HANSAPLAST AMPLOP 2613 @30 Pcs Pcs 1
9 HANSAPLAST JR 76768@10 MIXT Pcs Pcs 10
10 HANSAPLAST JR CARTOON 76505@10 Pcs Pcs 10
11 HANSAPLAST ROLL 1.25 X 1 1989 Pcs Pcs 10
12 HANSAPLAST TRANS 92733 Pcs Pcs 10
13 HEROCYN BEDAK 150GR Pcs Pcs 6
14 KALMETHASONE 0.5MG TAB@200 Tablet Box 1
15 LIVRON - B PLEX TAB @ 100 Tablet Box 1
16 MINYAK TAWON (CC) Botol Botol 8
17 MINYAK TAWON (DD) Botol Botol 8
18 MINYAK TAWON (EE) Botol Botol 5
19 MINYAK TAWON (FF) Botol Botol 5
20 MYLANTA FORTE SUSP 150ML Botol Botol 8
21 MYLANTA FORTE TAB@100 Tablet Box 1
22 MYLANTA SYRUP 150 ML Botol Botol 8
23 MYLANTA SYRUP 50 ML Botol Botol 8
24 MYLANTA TAB @ 100 Tablet Box 1
25 NEURALGIN NEW TAB@144 Tablet Box 1
26 NIZORAL 200MG TAB@150 Tablet Box 1
27 NIZORAL-SS 2% SHAMPO 80ML Botol Botol 2
28 OBAT BATUK IBU & ANAK 150ML Botol Botol 8
29 OBAT BATUK IBU & ANAK 75ML Botol Botol 8
30 PLANOTAB TAB@20 Tablet Box 1
31 POSTINOR-2 TAB@2 Tablet Box 12

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-421675
2 ANTASIDA DOEN SUSPENSI Botol Botol 5
3 ASIFIT KAPLET-BLISTER 3X10 KA Tablet Box 10
4 AUTOCHECK URIC ACID STR@25 Strip Box 10
7 BETADINE FEMININE HYGIENE 60 M Botol Botol 4
11 BETASON N KRIM Tube Box 1
12 BURNAZIN CREAM 35 GR Tube Tube 2
13 CAPTOPRIL 12.5 MG-STRIP 10X10 TA Tablet Box 3
16 CENDO CATARLENT MINIDOSE 5 X 0 Botol Botol 3
17 CETIRIZINE 10 MG TABLET SALUT Tablet Box 4
18 DEGIROL LOZ @ 100 (UN) Tablet Box 3
19 DEXOCORT 0.25 % CREAM Tube Tube 1
26 FUROSEMIDE 40 MG-STRIP 20X10TA Tablet Box 1
27 GENTAMYCIN 0,1 % SALEP KULIT Tube Box 1
29 KAMAFLAM 50 MG TABLET SALUT GU Tablet Box 10
30 KASA PEMB HYDR 4MX15CM KH Pcs Pcs 20
32 KETOCONAZOLE 2% CR GKF Tube Box 1
33 KETOCONAZOLE 200 MG-STRIP 5X10 Tablet Box 2
34 KLOTAREN 50 MG TABLET SALUT EN Tablet Box 6
35 LAXING KAPSUL @ 100 Kapsul Box 2
38 METRONIDAZOLE 500 MG.-STRIP 10 Tablet Box 2
41 ORALIT 200 ML-DUS 100 SASE Sachet Box 1
42 PARACETAMOL 500 MG 100 TAB STR Tablet Box 10
43 PEDITOX LOT 50ML Botol Botol 10
47 VAGIZOLE OVULA Tablet Box 2
51 VITAMIN B COMP TAB@1000 GKF Tablet Box 1
52 VITAMIN B1 100MG TAB@1000 GKF Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 FLADYSTIN OVULA @ 10 SUPP Supp Box 2

2 METFORMIN 500MG TAB@100 GDX Tablet Box 5

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT United Dico Citas
Alamat : Jalan Sumbawa No. 21 Surabaya
Telp : 031-5632268

1 VITACIMIN BLUEBERRY TAB@100 Tablet Box 1
2 VITACIMIN ORANGE TAB@100 Tablet Box 1
3 VITACIMIN SWEET TAB@100 Tablet Box 1
4 FG TROCHES @ 300 TAB Tablet Box 1
5 VITALONG C 500MG CAP@100 Kapsul Box 1
6 BORRAGINOL N OINT 15GR Tube Tube 2
7 BORRAGINOL-S OINT Tube Tube 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Penta Valent
Alamat :
Telp :
1 PROGESIC 500MG TAB@100 Tablet Box 3
2 PROGESIC 250MG/5ML SYR 60ML Botol Botol 5
3 Tablet Box 10
4 Strip Box 10
5 Botol Botol 12
6 Botol Botol 12
7 Botol Botol 4
8 Botol Botol 8
9 Botol Botol 15
10 Botol Botol 15
11 Tube Box 1
12 Tube Tube 2
13 Tablet Box 3
14 Tablet Box 2
15 Tablet Box 2
16 Botol Botol 3
17 Tablet Box 4
18 Tablet Box 3
19 Tube Tube 1
20 Botol Botol 20
21 Botol Box 1
22 Botol Box 1
24 Tube Box 1
25 Tablet Box 10
26 Tablet Box 1
27 Tube Box 1
28 Tube Box 1
29 Tablet Box 10
30 Pcs Pcs 20
31 Pcs Pcs 30
32 Tube Box 1
33 Tablet Box 2
34 Tablet Box 6
35 Kapsul Box 2
36 Botol Botol 24
37 Botol Botol 24
38 Tablet Box 2
39 Tablet Box 2
40 Tablet Box 2
41 Sachet Box 1
42 Tablet Box 10
43 Botol Botol 10
44 Tablet Box 4
45 Botol Botol 15
46 Tablet Box 10
47 Tablet Box 2
49 Pcs Pcs 12
50 Pcs Pcs 12
51 Tablet Box 1
52 Tablet Box 1
53 Botol Botol 24
54 Botol Botol 24
55 Botol Botol 24
56 Botol Botol 24
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Sakajaja Makmur Abadi
Alamat : Jl. Mojopahit Blok Y No.8 Kaliwates Jember
Telp :
1 NEO RHEUMACYL NEURO TAB@10 Tablet Box 1
2 VISINE EXTRA ED 10ML Botol Botol 12
3 VISINE EYE DROPS PFIZER 6 ML Botol Botol 12
4 VISINE TEARS 6 ML Botol Botol 12
5 PONSTAN 500MG KPL@100 Kapsul Box 1
6 BIOPLACENTON JELLY Tube Tube 12
7 MYCORAL 200MG TAB@50 Tablet Box 1
8 MYCORAL CR 5 GR Tube Tube 8
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Tempo
Alamat :
Telp :

1 BODREXIN DEMAM SYR 30ML Botol Botol 5
2 BODREXIN DEMAM SYR 60ML ORANGE Botol Botol 5
3 BODREXIN PILEK ALERGI SYR 60ML Botol Botol 5
4 OSKADON SP TAB@100 Tablet Box 1
5 OSKADON MIGRA TAB@100 Tablet Box 1
6 OSKADON EXTRA TAB@100 Tablet Box 1
7 IPI VITAMIN C TAB@50 Tablet Box 12
8 IPI VITAMIN B COMPLEX TAB@50 Tablet Box 12
9 IPI VITAMIN B12 TAB@50 Tablet Box 12
10 DOLOFEN F 400MG CAP@100 Kapsul Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 RENABETIC Tablet Box 3
2 Botol Botol 5
3 Tablet Box 10
4 Strip Box 10
5 Botol Botol 12
6 Botol Botol 12
7 Botol Botol 4
8 Botol Botol 8
9 Botol Botol 15
10 Botol Botol 15
11 Tube Box 1
12 Tube Tube 2
13 Tablet Box 3
14 Tablet Box 2
15 Tablet Box 2
16 Botol Botol 3
17 Tablet Box 4
18 Tablet Box 3
19 Tube Tube 1
20 Botol Botol 20
21 Botol Box 1
22 Botol Box 1
24 Tube Box 1
25 Tablet Box 10
26 Tablet Box 1
27 Tube Box 1
28 Tube Box 1
29 Tablet Box 10
30 Pcs Pcs 20
31 Pcs Pcs 30
32 Tube Box 1
33 Tablet Box 2
34 Tablet Box 6
35 Kapsul Box 2
36 Botol Botol 24
37 Botol Botol 24
38 Tablet Box 2
39 Tablet Box 2
40 Tablet Box 2
41 Sachet Box 1
42 Tablet Box 10
43 Botol Botol 10
44 Tablet Box 4
45 Botol Botol 15
46 Tablet Box 10
47 Tablet Box 2
49 Pcs Pcs 12
50 Pcs Pcs 12
51 Tablet Box 1
52 Tablet Box 1
53 Botol Botol 24
54 Botol Botol 24
55 Botol Botol 24
56 Botol Botol 24
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : Mensa Bina
Alamat :
Telp :

1 FRESHCARE CITRUS 10ML Botol Botol 12
2 FRESHCARE ROLL ON AROMATHERAPY Botol Botol 12
3 FRESHCARE ROLL ON SPLASH FRUIT Botol Botol 12
4 FRESHCARE ROLL ON LAVENDER Botol Botol 12
5 FRESHCARE ROLL ON STRONG Botol Botol 12
6 FRESHCARE SANDALWOOD 10ML Botol Botol 12
7 FRESHCARE SPORT 10ML Botol Botol 12
8 FRESHCARE TEENS BUBBLE GUM Botol Botol 12
9 FRESHCARE TEENS HAPPY CERRY Botol Botol 12
10 FRESHCARE TEENS PASSION FRUIT Botol Botol 12

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 DIGENTA CR 10GR Tube Tube 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000

2 KALPANAX TINCT 10ML Pcs Pcs 20
3 THROMBOPHOB GEL (NORDMARK) Tube Tube 6
5 ISORIC 100 MG TAB @ 50 Tablet Box 1
6 ISORIC 300 MG TAB @ 50 Tablet Box 1
7 OTOPAIN EAR DROP 8ML Botol Box 2
8 ENTRASOL GOLD 185GR PLAIN Pcs Pcs 2
10 ENTRASOL GOLD 2X185GR PLAIN Pcs Pcs 2
11 ENTRASOL GOLD 2X185GR VANILA Pcs Pcs 2
12 ENTRASOL GOLD 2X185GR COKLAT Pcs Pcs 2
13 ENTRASOL ACTIVE VANILA LATE160 Pcs Pcs 2
14 NEPHRISOL D 185GR Pcs Pcs 6
15 PROFERTIL 50MG TAB@10 Pcs Pcs 4
20 PAMOL FORTE TAB@60 Tablet Box 1
21 PAMOL 500MG TAB@100 Tablet Box 1
31 WOODS COUGH SIRUP ATT 60 ML Botol Botol 10
33 WOODS LOZENGES@6 Pcs Box 1
34 WOODS LOZENGES@6 CHERRY Pcs Box 1
35 WOODS LOZENGES@6 LEMON Pcs Box 1
36 WOODS LOZENGES@6 ORANGE Pcs Box 1
37 WOODS PEPP LOZ@6 EXTRA STRONG Pcs Box 1
38 WOODS PEPP PAED SYR 120ML Botol Botol 4
39 WOODS PEPP PAED SYR 60ML Botol Botol 4
41 THIAMYCIN 500MG CAP@100 Kapsul Box 1
42 KALTROFEN 100MG SUPP@10 Supp Box 1
43 KALTROFEN 100MG TAB@30 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 BRALIFEX 0.3% EYE DROP 5ML Botol Botol 6

2 BRALIFEX PLUS EYE DROP 5ML Botol Botol 6
4 EPISAN SUSP 100ML Botol Botol 2
5 FORMYCO 200MG TAB@50 Tablet Box 2
8 SANMAG SUSP 120ML Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 REGROU 2% TOP SOL30ML Tube Tube 2

2 SCABIMITE 5% CR 30GR Botol Botol 2
3 SCABIMITE 5% CR 10GR Tablet Box 2
4 LACTO - B 1 gr Tablet Box 1
5 CLINOVIR 400MG TAB@30 Tube Tube 1
15 PRORIS CHEW TAB@20 Tablet Box 5
18 PUREBABY CLEANS DIAPER CR 100G Tube Tube 3
19 PUREBABY LOT 80ML Botol Botol 1
21 PUREBABY SOOTHING CR 100GR Tube Tube 2
23 PUREKIDZ ITCHY CREAM 10GR Tube Tube 2
25 SARI KURMA AL-JAZIRA 330ML Botol Botol 8
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 CALCIUM D REDOXON FORTOS@10 Tablet Box 2

2 REDOXON FORTIMUN EFF@10 Tablet Box 3
3 REDOXON ZINC EFF@10 ORANGE Tablet Box 3
4 LACTACYD LIQ BABY 250ML BLUE Botol Botol 3
5 LACTACYD WOMAN 230 ML Botol Botol 3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 031-8439839
1 PANADOL SYRUP 30 ML Botol Botol 6

2 PANADOL DROPS Botol Botol 6
3 PANADOL 160 MG @60 ML SYR Botol Botol 6
4 JOINTFIT EXTRA ROLLER GEL 35GR Botol Botol 3
5 MALTOFER SYR 150 ML Botol Botol 2
6 OBH COMBI BATUK BERDAHAK MENTH Botol Botol 6
7 ENERVON - C TAB @ 30 (UN) Tablet Box 3
8 SILEX SYRUP 100 ML Botol Botol 6
9 SEVEN SEAS BECOMBION LYSINE SY Botol Botol 3
11 VOLTAREN EMULGEL 5GR Botol Botol 6
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 0331-428184
1 REGROU 2% TOP SOL30ML Botol Botol 2

2 PARASOL SPF33 CR 20GR Tube Tube 3
8 SUSU KAMBING ETAWA 250GR Sachet Box 3
9 SUTRA KLASIK KONDOM@12 Pcs Pcs 4
10 SUTRA OK KONDOM@12 Pcs Pcs 4
11 FIESTA STRAW KONDOM@3 Pcs Pcs 2
14 SUTRA PERKASA CAP@2 Kapsul Box 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :

2 AKURAT COMPACT Strip Box 2
3 SENSITIF Strip Box 2
4 PROFEN SIRUP 60 ML (GDN) Botol Botol 3
5 EYEVIT SYR 60ML Botol Botol 6

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 NORAGES SYR 60ML Botol Botol 2

2 NYSTIN DROP 12ML Botol Botol 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 OPTALVIT PLUS TAB@30 Tablet Box 2


No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 POLYSILANE GRAN CAP@60 Kapsul Botol 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 ASAM MEFENAMAT 500MG TAB GBER Tablet Box 1

2 CAPTOPRIL 12.5MG TAB@100 GDX Tablet Box 1
3 KALIUM DIKLOFENAK 50MG GDX Tablet Box 1
4 GLIMEPIRIDE 1MG TAB@50 GDX Tablet Box 1
5 PIRACETAM 800MG TAB@50 GDX Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 EMTRIX 10ML Pcs Pcs 3

2 COMTUSI SYR 60ML Botol Botol 1
3 COMTUSI SYRUP 100 ML Botol Botol 1
4 DEPAKENE SYR 120ML Botol Botol 2
5 DERMOVEL 0.1% CR 5GR Tube Tube 1
6 DERMOVEL 0.1% CR 10GR Tube Tube 1
7 DIPROGENTA CR 5GR Tube Tube 1
8 DULCOLACTOL SYR 60 ML Botol Botol 6
10 DULCOLAX 5 MG ECT 80 TAB Tablet Box 1
11 ENERVON - C TAB @ 30 (UN) Tablet Box 1
12 FLAGYSTATIN OVUL@10 Tablet Box 2
13 ILIADIN 0.025% NASAL DROP 10ML Botol Botol 1
14 INSTO EYE DROP 7.5 ML Botol Botol 16
15 INSTO EYE DROPS 15 ML Botol Botol 2
18 MUCOPECT 15 MG/5 ML SYRUP Botol Botol 2
19 MUCOPECT 7,5 MG/ML DROPS Botol Botol 1
20 NAPREX TST RITE 250 MG/60 ML ( Botol Botol 2
21 NATUR E FACE CREAM 50 ML Pcs Pcs 4
22 NATUR-E ADVAN NIGHT CREAM 30GR Pcs Pcs 1
23 NATUR-E NR CAP 300 IU@16 Kapsul Box 4
24 PANADOL CAPL 100 S Kapsul Box 1
25 PANADOL SYRUP 30 ML Botol Botol 6
27 PHARMATHON FORMULA @ 50 CAPS Kapsul Box 1
28 REDOXON ZINC EFF@10 BLACKCURRA Tablet Botol 1
29 REDOXON ZINC EFF@10 ORANGE Tablet Botol 5
30 SANGOBION SYR 100ML Botol Botol 2
31 SANGOBION VITA - TONIK 250ML Botol Botol 4
32 SCOTT EMULSION VITA 400 ML Botol Botol 4
33 SENSODYNE REP&PRO XTRA FRES100 Pcs Pcs 6
34 SILEX SYRUP 100 ML Botol Botol 9
35 TONIKUM 330 ML SYR (NEW) Botol Botol 4
37 ULTRAPROCT N CR 10GR Tube Tube 1
38 VENTOLIN EXP SYR 100ML Botol Botol 1
39 VENTOLIN INHALER Pcs Pcs 3
40 VENTOLIN NEBULES 2,5 MG Pcs Box 1
43 VICKS FORMULA 44 ANAK 54 ML ST Botol Botol 6
46 VOLTAREN 50MG TAB@50 Tablet Box 1
47 ZINCPRO SYRUP Botol Botol 3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 0331-326716
1 DIFLUCAN 150MG CAP@5 Kapsul Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 ERYSANBE SYR 60ML Pcs Pcs 2

2 FORMYCO CR 10GR Botol Botol 2
4 CINOLON N CR 10GR Botol Botol 2
5 CERINI SYR 60ML Tube Tube 2
6 BUFECT FORTE SUSP 60ML Tube Tube 5
7 BUFECT SUSP 60ML Tube Tube 7
8 FOLAVIT 400MCG TAB@100 Botol Botol 1
9 ANTANGIN JRG CAIR 15ML SACH@12 Tablet Box 7
10 ANTANGIN GINGERMINT 15 ML @12 Tablet Box 5
12 OB HERBAL ZIPLONG SC@5 Tablet Box 2
15 DETTOL BODY W FRESH 300ML BTL Botol Botol 1
16 DETTOL BODY W LAST 300 FRESH Botol Botol 1
17 DETTOL HIS SOOTHE 50 ML Botol Botol 2
18 DETTOL SOAP 65GR ACTIVE Botol Botol 3
19 DETTOL SOAP FRESH 105GR Botol Botol 3
20 DUREX FETHERLITE KONDOM@ 3 Botol Botol 2
21 DUREX PERFORMA KONDOM@ 3 Pcs Pcs 4
22 DUREX PLAY 100ML Pcs Pcs 2
23 DUREX PLAY 50ML Kapsul Box 5
24 DUREX RIBBED KONDOM@ 3 Kapsul Box 2
25 KY JELLY PERSONAL 50GR Botol Botol 3
26 STREPSIL REG@ 12 Botol Botol 9
27 VEET H.REMOVAL CR NORMAL 25GR Kapsul Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 SANADRYL EXP SYR 60ML Botol Botol 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
URAT PEMESANAN OBAT

Telp :
1 FERRIZ DROP Botol Botol 1
5 ROHTO TM 10ML Botol Botol 7
6 TRACETATE SUSP 200ML Botol Botol 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 SELSUN YELLOW 120ML Botol Botol 3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
49 NEXCARE DAILY MASK VALUE PACK Pcs Pcs 10
50 NEXCARE BANDAGE TWP TRANSPAREN Pcs Pcs 2
52 SYMBICORT 160/4.5 TURBU 60DOS Pcs Pcs 2
54 VAGISTIN OVUL@10 Tablet Box 1
55 VICEE LEMON TAB @ 100 (UN) Tablet Box 1
56 VICEE STRAWBERY TAB @ 100 (UN) Tablet Box 1
57 VICEE GRAPE TAB @ 100 (UN) Tablet Box 1
58 VICEE ORANGE TAB @ 100 (UN) Tablet Box 1
59 ZITHROMAX 500MG TAB@3 Tablet Box 1
60 VICKS FORMULA 44 ANAK 27 ML Botol Botol 5
61 VICKS INHALER (6 SX48) Pcs Pcs 18
64 VOLTAREN EMULGEL 1 % 20 GRAM Tube Tube 6
65 VOLTAREN EMULGEL 10 GRAM Tube Tube 6
66 VOLTAREN 50MG TAB@50 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

2 ACETYLCYSTEIN 200MG@100 GNOV Tablet Box 1
4 FIESTA MINT KONDOM@3 Pcs Pcs 3
5 FIESTA PASSION KONDOM@3 Pcs Pcs 3
7 BENZOLAC 5% GEL 5GR Tube Tube 3
15 DESOLEX N CR 10GR Tube Tube 3
16 DESOLEX OINT 10GR Tube Tube 3
18 LAXAREC ENEMA 5ML Pcs Pcs 6
19 METHYL PREDNISOLON 8MG GN0V Tablet Box 1
20 MOFACORT CR 5GR Tube Tube 2
31 SUCRALFATE SUSP 200ML GEP Botol Botol 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

2 METHYL PREDNISOLON 8MG GN0V Kapsul Box 1
3 DIRECTTEST CAWAN URINE Strip Pack 1
10 NOURISH SKIN TAB@15 Tablet Box 3
11 NOURISH SKIN ULTIMATE TAB@15 Tablet Box 4
13 PUREBABY RASH CREAM 50GR Pcs Pcs 2
14 PUREKIDS INHALANT 10ML Pcs Botol 5
15 PUREBABY LOT 80ML Pcs Botol 3
24 TS SWT CLASSIC@50 Pcs Pcs 2
25 TS SWT SACH@25 Pcs Pcs 1
26 SKRINER MASKER MULTI FUNGSI@5 Pcs Pcs 11
28 ZAMEL DROP 16ML Botol Botol 1
29 SENSIPAD ALAS POPOK L@10 Pcs Pack 2
30 SUTRA RM KONDOM@ 3 Bks Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

2 MAGALAT SUSP 100ML Botol Botol 1
4 PEDIALYTE SOL 500ML Botol Botol 2
5 SUPREME EFFERVESCENT BLACKCURA Pcs Pcs 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 ACTIMOVE MITELLA ARM SLING S Pcs Pcs 3

2 LEUKOMED T PLUS 8 X 15CM Pcs Pcs 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-5632268

1 VITACIMIN BLUEBERRY TAB@100 Tablet Box 1
3 SP TROCHES@12 MELON Tablet Box 1
4 SP TROCHES@12 STRAW Tablet Box 1
5 APPETON WEIGHT ADULT 450 COKLA Pcs Pcs 1
6 APPETON WEIGHT ADULT 450 VANIL Pcs Pcs 1
7 PROSOGAN FD 30MG TAB@28 Tablet Box 1
8 BORRAGINOL-S SUPP Supp Supp 1
9 BORRAGINOL N OINT 15GR Tube Tube 2
10 BORRAGINOL-S OINT Tube Tube 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-487380

3 EVER E 250MG CAP@12 Kapsul Box 4
7 JESSCOOL HANGER TAB EFF@20 Pcs Pcs 20
8 JESSCOOL TAB EFF@ 6 Tab Box 10
9 KONICARE BDK BIANG KERINGAT 80 Botol Botol 3
10 KONICARE BABY DIAPER RASH CR60 Botol Botol 3
11 KONICARE PENGURANG GATAL 30ML Botol Botol 7
13 KONICARE SKIN RELIEF GEL 60GR Botol Botol 3
19 FROZZ BLUEBERRY MINT Pcs Pcs 8
20 FROZZ BARLEY MINT Pcs Pcs 8
21 FROZZ CHERRY MINT Pcs Pcs 8
22 FROZZ COOL MINT 15 GR Pcs Pcs 8
23 FROZZ LIME MINT 15GR Pcs Pcs 8
24 FROZZ MINT Pcs Pcs 8
25 FROZZ ORANGE MINT 15GR Pcs Pcs 8
26 NANO-NANO KULIT JERUK 20 BTR Pcs Box 1
27 KONIDIN Tablet Box 1
28 KONIDIN STRONGMINT LOZ@6 MERAH Pcs Box 1
29 KONIDIN MINT LOZ@6 HIJAU Pcs Box 1
30 KONIDIN HERBAL MINT LOZENGES Pcs Box 1
31 PROTECAL SOLID EFF TAB@10 TUBE Tablet Tube 3
32 PROTECAL OSTEO TUBE Tablet Tube 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

3 CEFADROXIL 500MG CAP@100 GDX Kapsul Box 1
4 GLUVAS 2MG TAB@50 Tablet Box 2
5 KARY UNI EYE DROP 5ML Botol Botol 3
6 ASVEX 33.21MG TAB@100 Tablet Box 1
8 TARIVID 0.3% EYE DROP 5ML Botol Botol 3
9 AVAMYS 120 NASAL SPRAY Pcs Pcs 3
10 VOLTADEX GEL 20GR Tube Tube 2
11 TERRA CORTRIL EYE OINT 3.5GR Tube Tube 3
13 PEDIALYTE 500ML B.GUM(PINK) Botol Botol 3
14 MERTIGO 6MG TAB@100 Tablet Box 1
16 KETOCONAZOL 200MG TAB@50 GDX Tablet Box 1
18 GLUCODEX 80MG TAB@100 Tablet Box 1
19 SUPREME EFFERVESCENT BLACKCURA Pcs Pcs 1
20 PEDIASURE COMPLETE 400GR VANIL Pcs Pcs 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-3821110
1 BABY COUGH SYR 60ML Botol Botol 8

2 BERSIH DARAH KEMBANG BULAN Pcs Pcs 6
3 NEW GUANISTREP SYR Botol Botol 3
4 CAP KAPAK M ANGIN 28ML Botol Botol 4
6 OBH 100ML ITRASAL Botol Botol 7
11 DEXTEEM PLUS TAB@100 Tablet Box 1
13 BODREXIN FLU & BATUK SYR 56ML Botol Botol 4
14 OBP SYR 100ML ITRASAL Botol Botol 7
15 PLANOTAB TAB@20 Strip Strip 20
16 SALEP KULIT 88 6GR Pcs Pcs 1
17 SALONPAS LINIMENT 30ML Pcs Pcs 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

6 BENOSON CR 5GR Tube Tube 2
7 BENOSON N CR 5GR Tube Tube 2
8 BENOSON M CR 5GR Tube Tube 2
9 METHYL PREDNISOLON 4MG GNOV Tablet Box 1
13 DESOLEX CREAM Tube Tube 2
14 FAKTU OINT 20GR Tube Tube 2
15 FIESTA DURIAN KONDOM@3 Pcs Pcs 1
16 FIESTA PLEASURE KONDOM@12 Pcs Pcs 1
18 ZAMEL DROP 16ML Botol Box 2
19 SENSI SR TANGAN MEDIS L@60 Pcs Box 1
20 SENSI SR TANGAN MEDIS S@60 Pcs Box 1
21 SENSI POPOK DEWASA L@10 Pcs Box 3
22 SENSI POPOK DEWASA M@10 Pcs Box 3
23 SENSI POPOK DEWASA XL@8 Pcs Box 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 SENSI MASK 3PLY SURGICAL FAC Pcs Box 2

2 SENSI MASK 3PLY SURGICAL MASK Pcs Box 2
3 SENSI MASK 3PLY TIE ON@50 Pcs Box 2
4 SENSI MASK EARLOOP 3PLY BIRU Pcs Pcs 5
5 SENSI MASK EARLOOP 3PLY HIJAU Pcs Pcs 5
6 SENSI MASK DUCK BILL@50 Pcs Box 1
7 SENSI MASKER DUCKBILL@6 Pcs Pcs 3
9 COOLING 5 SPRAY 1.4% COOLMINT Pcs Pcs 4
10 COOLING 5 SPRAY 1.4% CHERRY Pcs Pcs 4

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 KOBELLON CAP@20 Kapsul Box 1

2 ELOX CREAM 5 GR (GDN) Tube Tube 3
3 CLINMAS 150MG CAP@30 Kapsul Box 1
4 CLINMAS 300MG CAP@30 Kapsul Box 1
5 THECORT CREAM 5 GR (GDN) Tube Tube 2
6 CLARIHIS 10MG TAB@30 Tablet Box 1
7 LAMESON 4MG TAB@100 Tablet Box 1
8 MUCOS 30MG TAB@100 Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
2 NIZORAL 1% SHAMPO 50ML Botol Botol 2
4 ANDALAN PIL KB Tablet Box 1
14 DIAPET CAP@100 Kapsul Box 1
15 DIAPET NR TABLET @ 100 Tablet Box 1
20 AQUA MARIS BABY NASAL DROPS Botol Botol 3
21 AQUA MARIS DAILY NASAL SPRAY Botol Botol 2
22 AQUA MARIS STRONG NASAL SPRAY Botol Botol 2
23 MYCO-Z OINT 10GR Tube Box 2
24 PRIMPERAN 10MG TAB@100 Tablet Box 1
25 PRIMPERAN 5MG TAB@100 Tablet Box 1
26 PRIMADOL KPL@100 Kapsul Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-3821110

2 BERSIH DARAH KEMBANG BULAN Pcs Pcs 6
3 NEW GUANISTREP SYR Botol Botol 3
6 OBH 100ML ITRASAL Botol Botol 7
8 BODREX EXTRA KPL@100 Botol Botol 5
9 BODREX FLU & BATUK Botol Botol 4
10 BODREX MIGRA Botol Botol 4
11 PLANOTAB TAB@20 Tablet Box 1
12 SALONPAS CR 30GR Kapsul Box 1
13 SALONPAS GEL 15GR Botol Botol 4
14 SALONPAS HOT CR 15GR Botol Botol 7
15 SALONPAS HOT CR 30GR Strip Strip 20
16 SALONPAS KOYO@10 Pcs Pcs 1
17 SALONPAS KOYO HOT @10 Pcs Pcs 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

2 TENSOCREPE 3 7,5CMX4,5M Pcs Pcs 1
3 TENSOCREPE 4 10CMX4,5M Pcs Pcs 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
5 CURCUMA + SHARPY ORANGE 60ML Botol Botol 2
11 IMBOOST FORCE SYRUP 60 ML Botol Botol 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839

2 ARCOXIA 90MG TAB@30 Tablet Box 1
3 ARDIUM 500MG TAB@30 Tablet Box 1
4 VENTOLIN 2MG TAB@30 Tablet Box 1
5 MUCOPECT 30 MG/5 ML SYRUP Botol Botol 1
6 MUCOPECT 30 MG TAB @ 100 (BOEH Botol Botol 1
7 DERMOVATE CR 5GR Tube Tube 1
8 PARIET 10MG TAB@14 Tablet Box 1
9 NEXIUM 20MG TAB@28 Tablet Box 1
13 SERETIDE DISKUS 250MCG Pcs Pcs 1
14 LAXOBERON DROP 10ML Botol Botol 2
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 0331-428184
1 PRORIS CHEW TAB@20 Botol Botol 5

3 SKRINEER HIJAB@5 Tube Tube 15
4 KETOMED 2% GEL 15GR Tablet Box 1
5 MEDIKLIN GEL Tablet Box 3
8 COOLING 5 SPRAY 1.4% CHERRY Tube Tube 6
9 COOLING 5 SPRAY 1.4% COOLMINT Tablet Box 4
11 SUTRA KLASIK KONDOM@12 Botol Botol 9
12 SUTRA OK KONDOM@12 Tube Tube 8
13 SUTRA RM KONDOM@12 Tube Tube 5
14 MAGIC POWER BLACK PARADE@6 Tube Tube 5
15 BENZOLAC-CL GEL 5GR Pcs Pcs 3
16 ISPRINOL SYR 60ML Pcs Pcs 2
17 NATRIUM DIKLOFENAK 50MG@50 GNV Pcs Pcs 2
18 SENSI SR TANGAN MEDIS L@60 Botol Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-3821110

4 KALMETHASONE 0.5MG TAB@200 Tablet Box 1
5 MOLACORT 0.5MG TAB@100 Tablet Box 1
7 LOPAMID TABLET @ 100 Tablet Box 1
8 ERLAMYCETIN EAR DROPS 1% Botol Botol 6
9 KALNEX 500MG TAB@100 Tablet Box 1
10 FLUIMUCIL 200MG CAP@60 Kapsul Box 1
11 CINDALA GEL 10GR Tube Tube 3
12 BERSIH DARAH KEMBANG BULAN Tablet Box 12
14 KALMICETINE 250MG CAP@100 Kapsul Box 1
15 KALMICETINE 2% OINT 15GR Tube Tube 2
16 OBP SYR 100ML ITRASAL Botol Botol 8
17 CPG 75MG TAB@30 Tablet Box 1
18 KOYO CABE @10 Sachet Box 2
21 ZINKID 10 MG/5 ML SYRUP @ 100 Botol Botol 3
22 NEUROPYRON @ 100 KAPLET Kapsul Box 1
23 SIDO M TOLAK ANGIN + MADU 15ML Sachet Box 6
24 SIDO M TOLAK ANGIN CAIR ANA@12 Sachet Box 2
26 MERCOTIN DROP 20ML Botol Botol 2
27 LANADEXON 0.5MG KPL@100 Kapsul Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

2 YAZ TAB@28 Tablet Box 1
3 YASMIN TAB@21 Tablet Box 1
4 CELEBREX 100MG CAP@30 Kapsul Box 1
7 CANDERIN 8MG TAB@30 Tablet Box 1
8 TROLIP 300MG CAP@30 Kapsul Box 1
10 BINOTAL 500MG CAP@50 Kapsul Box 1
11 BINOTAL 1000MG TAB@50 Tablet Box 1
12 GLUCOPHAGE 500MG TAB@100 Tablet Box 1
13 GLUCOVANCE 500/5MG TAB@100 Tablet Box 1
14 GLUCOVANCE 500/2.5MG TAB@100 Tablet Box 1
15 NORVASK 5 MG TAB @ 30 Tablet Box 1
16 VOLTAREN SR 75 MG FT TAB @ 50 Tablet Box 1
17 EUTHYROX 100MCG TAB@100 Tablet Box 1
18 PROVULA 50MG TAB@30 Tablet Box 1
19 PREGNOLIN 5MG TAB@50 Tablet Box 1
20 NEURODEX TAB@100 Tablet Box 1
21 SELOXY AA Tablet Box 1
22 TARIVID 0.3% EYE DROP 5ML Botol Botol 2
23 VOMETA 5MG/ML DROPS Botol Botol 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-487380

7 JESSCOOL HANGER TAB EFF@20 Pcs Pcs 20
8 JESSCOOL TAB EFF@ 6 Tab Box 10
10 KONICARE BABY DIAPER RASH CR60 Botol Botol 3
13 KONICARE SKIN RELIEF GEL 60GR Botol Botol 3
20 FROZZ BARLEY MINT Pcs Pcs 8
21 FROZZ CHERRY MINT Pcs Pcs 8
22 FROZZ COOL MINT 15 GR Pcs Pcs 8
23 FROZZ LIME MINT 15GR Pcs Pcs 8
24 FROZZ MINT Pcs Pcs 8
25 FROZZ ORANGE MINT 15GR Pcs Pcs 8
26 NANO-NANO KULIT JERUK 20 BTR Pcs Box 1
27 KONIDIN Tablet Box 1
28 KONIDIN STRONGMINT LOZ@6 MERAH Pcs Box 1
29 KONIDIN MINT LOZ@6 HIJAU Pcs Box 1
30 KONIDIN HERBAL MINT LOZENGES Pcs Box 1
31 PROTECAL SOLID EFF TAB@10 TUBE Tablet Tube 3
32 PROTECAL OSTEO TUBE Tablet Tube 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : Sapta Sari Tama
Alamat : Jln Teuku Umar, Perum Sumber Bendo Blok C No. 41 Jember
Telp : 0331-337065
1 CALLUSOL LOT 10ML Botol Botol 8

2 LASERIN MADU 110ML Botol Botol 2
3 THROMBOFLASH GEL 10GR Tube Tube 3
4 THROMBOFLASH GEL 20GR Tube Tube 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : Tempo
Telp : 0331-322818
1 BODREX MIGRA Tablet Box 1

2 OSKADON TAB@200 Tablet Box 1
3 SCANDEXON 0.5MG TAB@100 Tablet Box 1
4 BEROTEC 100MCG MDI Pcs Pcs 1
5 COMBIVENT 2.5ML UDV@10 Pcs Box 1
6 BODREXIN DEMAM SYR 60ML ORANGE Botol Botol 2
7 BODREXIN PILEK ALERGI SYR 60ML Botol Botol 2
8 BODREXIN FLU & BATUK SYR 56ML Botol Botol 2
9 HEMAVITON ACTION AMPLOP@50 Tablet Box 1
10 HEMAVITON STAMINA PLUS AMPLOP Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-5632268

1 VITACIMIN FRUIT PUCH TAB@100 Tablet Box 1
3 VITACIMIN ORANGE TAB@100 Tablet Box 1
4 APPETON WEIGHT ADULT 450 COKLA Pcs Pcs 1
5 APPETON WEIGHT ADULT 450 VANIL Pcs Pcs 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 LOPAMID TABLET @ 100 Tablet Box 1
2 SIMARC 2MG TAB@100 Tablet Box 1
3 RENABETIC Tablet Box 1
5 RECOLFAR 0.5MG TAB@30 Tablet Box 1
6 INPEPSA SUSP 200ML Botol Botol 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
4 DAKTARIN CREAM 10 GRAM Tube Tube 6
5 DAKTARIN CR 20GR Tube Tube 6
6 DAKTARIN DIAPER CR 10GR Tube Tube 6
7 VERMOX 500MG TAB@24 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Nama PBF : PT Penta Valent
Alamat :
Telp :
1 ICHTYOL SALEP 30GR CITO Pcs Pcs 10
2 VITAN TAB@20 Tablet Box 5
3 PROLACTA DHA FOR BABY CAP@50 Kapsul Box 1
4 PROLACTA DHA FOR MOTHER CAP@60 Kapsul Box 1
5 MINOSEP GARGLE 0.1% 150ML Botol Botol 5
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Alamat :
Telp :
1 SALONPAS KOYO@10 Pcs Pcs 1

3 FENOFIBRATE CAP@40 Kapsul Box 1
4 PLETAAL 100 MG TAB Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 KOBELLON CAP@20 Kapsul Box 1

2 MUCOS 30MG TAB@100 Tablet Box 1
4 SENSITIF Strip Box 1
5 IMUNOS KPL@20 Tablet Box 1
6 LAPISTAN 500MG TAB@100 Tablet Box 1
7 MOVIX 7.5MG TAB@20 Tablet Box 1
8 MOVIX 15MG TAB@20 Tablet Box 1
10 UTROGESTAN 200MG CAP@15 Kapsul Box 1
11 CEFILA 100MG CAP@30 Kapsul Box 1
12 IMUNOS SYR 60ML Botol Botol 2
13 ZIBRAMAX 500 MG KAPL @ 6 (GDN) Kapsul Box 1
14 CAL-95 KPL@30 Kapsul Box 1
15 NUTRIMAMA 2 SOFTGEL@30 Kapsul Box 1
16 FULADIC CREAM 5 GR (GDN) Tube Tube 2
17 FULADIC SALEP 5 GR (GDN) Tube Tube 2
18 PROMAVIT CAP@60 Kapsul Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Alamat : Jl. KH. Shiddiq no. 110 Jember
Telp : 0331-482332

1 FRESHCARE CITRUS 10ML Botol Box 1
2 FRESHCARE ROLL ON AROMATHERAPY Botol Box 1
3 FRESHCARE ROLL ON SPLASH FRUIT Botol Box 1
4 FRESHCARE ROLL ON LAVENDER Botol Box 1
5 FRESHCARE ROLL ON STRONG Botol Box 1
6 FRESHCARE SANDALWOOD 10ML Botol Box 1
7 FRESHCARE SPORT 10ML Botol Box 1
8 FRESHCARE TEENS BUBBLE GUM Botol Box 1
9 FRESHCARE TEENS HAPPY CERRY Botol Box 1
10 FRESHCARE TEENS PASSION FRUIT Botol Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

4 PEDIALYTE SOL 500ML Botol Botol 1
7 FLADYSTIN OVULA @ 10 SUPP Supp Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716


No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
3 FITKOM GUMMY MULTIVITAMIN@5 Sachet Box 2
6 PHAROLIT 5.8GR SACH@60 Sachet Box 1
7 NIZORAL-SS 1% SHAMPO 80ML Botol Botol 1
9 CURVIT CL EMULSION SIRUP 175 M Botol Botol 3
10 CURCUMA 10 x 10 BLISTER Tablet Box 1
11 CIPROXIN 500MG TAB@20 Tablet Box 1
12 ADALAT OROS 30MG TAB@30 Tablet Box 1
15 MATOVIT TAB@30 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 VICKS FORMULA 44 ADULT 100 ML Tablet Box 2

2 VICKS FORMULA 44 ADULT 54 ML Tablet Box 1
3 VICKS INHALER (6 SX48) Tablet Box 1
4 VICKS VAPORUB 10 GM Tablet Box 1
5 Botol Botol 1
6 Botol Botol 1
7 Tube Tube 1
8 Tablet Box 1
9 Tablet Box 1
10 Botol Botol 1
11 Botol Botol 4
12 Botol Botol 3
13 Pcs Pcs 1
14 Botol Botol 2
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Nama PBF : PT. Kallista Prima
Alamat : Jl Biliton No. 14 Surabaya
Telp :
1 SENOS OXYGEN Sachet Box 2
2 Sachet Box 2
3 Sachet Box 2
4 Sachet Box 2
5 Sachet Box 2
6 Sachet Box 1
7 Botol Botol 1
8 Tablet Box 2
9 Botol Botol 3
10 Tablet Box 1
11 Tablet Box 1
12 Tablet Box 1
13 Botol Botol 2
14 Botol Botol 2
15 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
1 ELLGY PLUS CRACKED HEEL CR 10G Tablet Botol 4
2 Sachet Box 3
3 Tablet Botol 6
4 Tablet Botol 2
5 Botol Botol 2
6 Sachet Box 3
7 Tablet Box 1
8 Botol Botol 1
9 Sachet Box 1
10 Sachet Box 1
11 Botol Botol 1
11 Tablet Box 1
12 Botol Botol 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184

2 SUTRA KLASIK KONDOM@12 Pcs Pcs 11
3 SUTRA OK KONDOM@12 Pcs Pcs 3
4 SUTRA RM KONDOM@12 Pcs Pcs 5
5 SUTRA RM KONDOM@ 3 Pcs Box 1
6 SUTRA OK KONDOM@ 3 Pcs Box 1
7 FIESTA MAX DOTTED@12 Pcs Pcs 1
8 FIESTA ALL NIGHT KONDOM@3 Pcs Pcs 1
9 MAGIC POWER BLACK PARADE@6 Pcs Pcs 6
13 SENSI SR TANGAN MEDIS L@60 Pcs Box 2
14 SENSI SR TANGAN MEDIS M@60 Pcs Box 1
15 SENSI SR TANGAN MEDIS S@60 Pcs Box 1
17 PRAXION FORTE SYR 60ML JERUK Botol Botol 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000

5 WOODS COUGH SIRUP ATT 60 ML Botol Botol 8
7 WOODS LOZENGES@6 Pcs Pcs 15
8 WOODS LOZENGES@6 CHERRY Pcs Pcs 15
9 WOODS LOZENGES@6 LEMON Pcs Pcs 15
12 KALTROFEN 100MG TAB@30 Tablet Box 1
13 KALTROFEN 100MG SUPP@10 Supp Supp 1
19 PROMAG SUSPENSI 7ML SACH@6 Sachet Sachet 2
22 INDEXON TAB@100 Tablet Box 1
25 ALOCLAIR PLUS ORAL RINSE 60ML Botol Botol 2
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 PAMOL DROP 15ML Botol Botol 4

8 ALLOPURINOL 300 MG (HEXA) Tablet Box 1
9 CEFADROXIL 500MG CAP@50 GHX Kapsul Kapsul 1
10 COLME EAR DROPS 8 ML Botol Botol 1
11 CEFSPAN 100MG CAP@30 Kapsul Box 1
12 ENTRAMIX 185GR VANILA Pcs Pcs 5
13 HEPATOSOL 185GR COKLAT Pcs Pcs 2
16 IRVASK 300MG TAB@30 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 NEO ENTROSTOP TAB@144 Table Box 4

3 THEOBRON 130MG CAP@100 Kapsul Box 1
4 TRIAMCORT 4MG TAB@100 Table Box 5
5 URINTER 400MG CAP@100 Kapsul Box 5
6 COLME EAR DROPS 8 ML Botol Botol 10
7 ENTROSTOP HERBAL ANAK SACH@6 Sachet Box 2
10 INTERHISTIN 50MG TAB@100 Table Box 1
11 INTERZOL 200MG TAB@50 Table Box 1
12 INVOMIT 4 MG TAB Table Box 5
13 INVOMIT 8MG TAB@18 Table Box 2
14 ISORIC 300MG TAB@50 Table Box 1
15 ISORIC 100 MG TAB @ 50 Table Box 3
16 MIXAGRIP CAPL Kapsul Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000
1 INTERBI 250MG TAB@12 Tablet Box 1

2 MEXTRIL TAB@100 Tablet Box 1
3 MEXTRIL SYR EXPECTORANT 60ML Botol Botol 4
4 MIXAGRIP FLU&BATUK TAB@100 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-335000

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 REGROU FORTE SOL 30ML Tube Tube 2

2 ONDANSETRON 4MG TAB@12 GNV Pcs Pcs 1
3 ONDANSETRON 8MG TAB@12 GNV Pcs Pcs 1
4 RAMIPRIL 10MG TAB@30 GNV Pcs Pcs 1
5 RAMIPRIL 5MG TAB@100 GNV Pcs Box 1
6 PIROTOP 2% CR 10GR Pcs Box 1
7 PIROTOP OINT 10GR Pcs Pcs 2
8 DESOLEX OINT 10GR Pcs Pcs 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-421675
1 MARCKS TEENS CP CREME Pcs Box 1

2 MARCKS TEENS CP INVISIBLE Pcs Box 1
3 MARCKS TEENS CP NATURAL BEIGE Pcs Box 1
4 MARCKS TEENS CP PINK Pcs Box 1
5 MARCKS TEENS CP PUTIH Pcs Box 1
6 MARCKS BEDAK PINK 20gr Pcs Box 1
7 MARCKS BEDAK Natural Beige 20 Pcs Box 1
8 MARCKS BEDAK CREME 20gr Pcs Box 1
10 MARCKS BEDAK Natural Beige 40g Pcs Pcs 12
11 MARCKS BEDAK ROSE Pcs Pcs 12
12 MARCKS BEDAK PUTIH Pcs Pcs 12
13 MARCKS BEDAK INVISIBLE 40gr (N Pcs Pcs 12
14 MARCKS MOISTURIZER 30GR Pcs Box 2
15 VENUS BODY SERUM ANTIAGING Pcs Pcs 30
17 VENUS F.TONER NORMAL& DRY 50 Pcs Pcs 6
18 VENUS FACE TONER - NORMAL SKIN 100 Pcs Pcs 6
19 VENUS FACE TONER - NORMAL SKIN 50 Pcs Pcs 6
20 VENUS FACE TONER - OILY SKIN 1 Pcs Pcs 6

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-421675

2 DEXOCORT 0,25%/10GR KRIM Tube Box 1
4 LOVEQUIN 500 MG-STRIP 2X10 TAB Tablet Box 2
8 KASA PEMB HYDR 4MX10CM Pcs Pcs 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

2 VOLTADEX 50MG TAB@50 Tablet Box 2
4 CEFIXIME 100 MG KAPSUL Kapsul Box 1
9 LIPITOR 20 MG TABLET Tablet Box 2
10 PROVULA 50MG TAB@30 Tablet Box 3
11 NEEDLE NOVOFINE 32G TIP ETW Pcs Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 INPEPSA SUSP 200ML Tablet Box 1
2 INPEPSA SYRUP 100 ML Tablet Box 2
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
6 CURCUMA + SHARPY STRAWBRY 60ML Botol Botol 1
14 DIAPET NR TABLET @ 100 Tablet Box 1
16 DIAPET CAP@100 Kapsul Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
1 AQUA MARIS DAILY NASAL SPRAY Botol Botol 1
3 ASEPSO PLUS CLEAN 80 GRAM Pcs Pcs 5
5 VEGETA SACH@ 6 JERUK Sachet Box 1
14 TANTUM VERDE ORAL RINSE 120ML Botol Botol 1
15 CURCUMA PLUS IMUNS 60 ML Botol Botol 3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-333318
1 CURVIT CL EMULSION SIRUP 175 M Pcs Pcs 2
3 CP GROWBCURRANT400ML Sachet Box 3
4 IMBOOST FORCE ES CPL@30 Botol Botol 1
5 TANTUM VERDE ORAL RINSE 60ML Tube Tube 5
6 BETADINE OINT 20 GRAM Botol Botol 5
7 BETADINE SOLUTION 30 ML Tablet Box 10
8 BETADINE SOLUTION 60 ML Tube Tube 8
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Alamat :
Telp :

2 VIP ALBUMIN 500MG CAP@30 Kapsul Box 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 FAKTU OINT 20GR Tube Tube 2

2 FASOLON CR 10GR Tube Tube 2
3 FASOLON CR 5GR Tube Tube 2
4 CARMED CR 10% 40GR Tube Tube 2
6 KETOMED 2% SCALP LOT 60ML Pcs Pcs 2
9 SENSI MASK EARLOOP 3PLY BIRU Pcs Pcs 8
10 SENSI MASK EARLOOP 3PLY HIJAU Pcs Pcs 8

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 INPEPSA SUSP 200ML Botol Botol 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
URAT PEMESANAN OBAT

Telp : 0331-421675

2 CHANNA CAP@30 Kapsul Box 2
5 ASIFIT KAPLET-BLISTER 3X10 KA Kapsul Box 5
6 FUROSEMIDE 40 MG-STRIP 20X10TA Kapsul Box 1
7 CIMETIDINE 200 MG.-STRIP 10X10 Tablet Box 1
8 GLIMEPIRIDE 1 MG TABLET Tablet Box 1
12 MELOXICAM 15 MG-STRIP 2X10 TAB Tablet Box 1
18 YOU-C 1000 LEMON WATER Botol Botol 24
20 MARCKS TEENS CP CREME Pcs Box 1
21 MARCKS TEENS CP INVISIBLE Pcs Box 1
22 MARCKS TEENS CP NATURAL BEIGE Pcs Box 1
23 MARCKS TEENS CP PINK Pcs Box 1
24 MARCKS TEENS CP PUTIH Pcs Box 1
25 MARCKS MOISTURIZER 30GR Pcs Box 2
26 VENUS SOFT MATTE LIPCREAM NO.3 Pcs Box 1
31 VENUS SOFT MATTE LIPCREAM 10 Pcs Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-428184
1 REGROU FORTE SOL 30ML Pcs Pcs 2

4 RAMIPRIL 10MG TAB@30 GNV Tablet Box 1
5 RAMIPRIL 5MG TAB@100 GNV Tablet Box 1
6 VAPORIN CAP INHALASI@10 Kapsul Box 3
7 KETOPROFEN 100MG TAB@100 GNV Tablet Box 1
15 KETOMED 2% SCALP LOT 60ML Pcs Pcs 2
16 OSTOVELL 0.25MCG CAP@30 Kapsul Box 1
17 NUCRAL SUSP 100 ML(GDN) Botol Botol 2
18 SARUNG TANGAN S(SENSI) Pcs Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

7 VOLTADEX 50MG TAB@50 Tablet Box 2
8 STATOR 10MG TAB@30 Tablet Box 1
9 STATOR 20MG TAB@30 Tablet Box 1
10 MEDIXON 4MG TAB@100 Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
6 VIAGRA 100MG TAB@4 Tablet Box 1
8 DAKTARIN CREAM 10 GRAM Tube Tube 6
9 DAKTARIN CR 20GR Tube Tube 6
10 DAKTARIN DIAPER CR 10GR Tube Tube 6
11 VERMOX 500MG TAB@24 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928
1 REGUMEN TAB@30 Tablet Box 1

2 FLAMAR 50MG TAB@100 Tablet Box 1
3 ACRAN 150MG TAB@30 Tablet Box 1
4 SANMETIDIN 200MG TAB@100 Tablet Box 1
5 VOSEDON 10MG TAB@100 Tablet Box 1
6 EPEXOL 30MG TAB@100 Tablet Box 1
11 SANEXON 8MG TAB@100 Tablet Box 1
12 CORTIDEX 0.5MG TAB@100 Tablet Box 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 DIPROGENTA OINT 5GR Tube Tube 2

3 DIPROGENTA OINT 10GR Tube Tube 2
6 DETTOL HIS SOOTHE 50 ML Pcs Pcs 4
7 DETTOL IHS ORIG 50 ML Pcs Pcs 4
8 DETTOL SOAP RE-ENERGIZE 65GR Pcs Pcs 4
9 DETTOL SOAP ORIGINAL 110 GR Pcs Pcs 4
10 DETTOL SOAP 65GR ACTIVE Pcs Pcs 4
11 COMBIVENT 2.5ML UDV@10 Pcs Box 1
12 BEROTEC 100MCG MDI HFA Pcs Pcs 2
13 BURNAZIN CREAM 35 GR Tube Tube 2
16 BISOLVON FLU & BATUK SYR 60ML Botol Botol 8
17 BISOLVON FLU & BATUK SYR 125ML Botol Botol 4
21 CANESTEN CREAM 3 GR Tube Tube 10
24 CELESTAMINE TAB@150 Tablet Box 1
25 EXLUTON LIMAS@3 Tablet Box 2
26 FLAGYL FORTE 500MG TAB@100 Tablet Box 1
27 FLAGYL 500MG SUPP@10 Supp Box 1
28 FLAGYL 1000MG SUPP@10 Supp Box 1
29 FLAGYL SYR 60ML Botol Botol 3
30 GARAMYCIN CR 5GR Tube Tube 3
31 GARAMYCIN CR 15GR Tube Tube 2
32 GARAMYCIN OINT 5GR Tube Tube 3
33 GARAMYCIN OINT 15GR Tube Tube 2
35 NEXCARE DAILY HIJAB MASK Pcs Pcs 15
36 NEXCARE DAILY MASK VALUE PACK Pcs Pcs 10
37 NEXCARE BANDAGE TWP TRANSPAREN Pcs Pcs 2
38 NEXCARE MICROPORE 1 INCH X 10 Pcs Pcs 3
39 VICEE LEMON TAB @ 100 (UN) Tablet Box 1
40 VICEE ORANGE TAB @ 100 (UN) Tablet Box 1
44 VICKS INHALER (6 SX48) Pcs Pcs 18
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 0331-487380

6 JESSCOOL HANGER TAB EFF@20 Tablet Box 3
10 NATUR E 100 IU SOFT CAP @ 32 Kapsul Box 4
11 NUTRICAN PWD 245GR Sachet Box 3
13 SILADEX M & E 100ML Botol Botol 1
16 VIGEL GEL 60GR Pcs Pcs 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 NEXCARE MICROPORE 1 INCH X 10 Pcs Pcs 4

2 NIFURAL SYR Botol Botol 1
3 NIPE DROP 15ML Botol Botol 1
4 OBH COMBI BATUK BERDAHAK MENTH Botol Botol 4
7 SANGOBION VITA - TONIK 250ML Botol Botol 1
8 ESPERSON 0.25% CR 15GR Tube Tube 1
9 ESPERSON 0.25% CR 5GR Tube Tube 3
10 INSTO EYE DROPS 15 ML Botol Botol 5
12 MEBO OINT 20GR Tube Tube 1
13 NATUR E ADVANCED 32 S Kapsul Box 1
14 NATUR E SOFT CAPS @ 16 Kapsul Box 3
15 CALCIUM D REDOXON EFF@10 Tablet Box 3
16 CALCIUM D REDOXON FORTOS@10 Tablet Box 1
17 DERMOVATE CR 5GR Tube Tube 1
19 DERMOVATE OINT 10GR Tube Tube 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 0331-333318
6 TANTUM VERDE ORAL RINSE 120ML Botol Botol 3
9 AQUA MARIS STRONG NASAL SPRAY Pcs Pcs 4
12 CURCUMA + SHARPY STRAWBRY 60ML Botol Botol 2
3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 CONCOR 2.5MG TAB@100 Tablet Box 1

2 CRAVIT 0.5% EYE DROP 5ML Botol Botol 2
4 ENSURE VAN 400GR Pcs Pcs 4
9 GOLDEN GINGER SF CLASSIC 45GR Pcs Pcs 1
12 LIPITOR 20 MG TABLET Tablet Box 1
14 PEDIALYTE 500ML B.GUM(PINK) Botol Botol 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

4 TENSOCREPE 3 7,5CMX4,5M Pcs Pcs 2
5 TENSOCREPE 4 10CMX4,5M Pcs Pcs 4
6 TENSOCREPE FL 6 INCH 15 X4.55M Pcs Pcs 3

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp :
1 BETADINE VAGINAL DOUCHE TA 100 Botol Botol 1
4 MYCORAL CR 5GR Tube Tube 3
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-8439839
1 BISOLVON 8 MG TAB @ 100 TAB Tablet Box 1

2 BISOLVON EXTRA SYR 125ML Botol Botol 1
4 DULCOLAX 5 MG ECT 80 TAB Tablet Box 1
5 LACTACYD BABY 150 ML Botol Botol 1
6 MUCOPECT 7,5 MG/ML DROPS Botol Botol 1
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
o

Telp : 0331-326716

2 DOMPERIDONE 10MG TAB@100 GDX Tablet Box 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 010/IX/2018

Telp : 031-3821110

Farmasi Sediaan
1 Demacolin Tab Dextrometorphan 7.5mg Tablet Box/100 6
3 Demacolin Syr Dextrometorphan 7.5mg Sirup Botol 10

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
I
Ket
jawab
i,S.Farm.,Apt.
14/II/2017

Telp : 031-3821110

2 GANDAPURA 30 ML (IKA ) Pcs Pcs 4
3 GANDAPURA 60 ML (IKA ) Botol Botol 4
4 GANDAPURA 100 ML (IKA ) Botol Botol 3
5 KALPANAX TINCT 10ML Botol Botol 15
6 PAGODA SALEP EXTRA 10GR Botol Botol 5
11 SALEP KULIT 88 6GR Tablet Box 12
12 LION HEAD BALM 13GR Kapsul Box 3
13 LION HEAD BALM 16GR Botol Botol 3
14 LION HEAD BALM 31GR Botol Botol 3
15 HOT IN CREAM PUMP 120ML Strip Strip 3
16 HOT IN CREAM TUBE 120GR Pcs Pcs 3
18 ICHTYOL Tube Tube 6

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,
440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

2 DOMPERIDONE 10MG TAB@100 GDX Tablet Box 2
14 FISHERMANS SF LEMON 25GR Pcs Pcs 5
16 PEDIASURE COMPLETE 400GR VANIL Pcs Pcs 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716

5 NEURODEX DRAG @ 200 Tablet Box 2

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-332928

5 AMOXSAN 250MG/5ML SYR 60ML Botol Botol 4
9 NEUROSANBE PLUS KPL@100 Kapsul Box 1
16 UROTRACTIN 400MG CAP@60 Kapsul Box 1
18 CINOLON N CR 10GR Tube Tube 3
20 FORMYCO 200MG TAB@50 Tablet Box 2
22 LODIA FILM-COATED TAB Tablet Box 2
24 CEFAT FORTE SYR 60ML Botol Botol 2
26 DETTOL BODY W COOL 300ML BTL Botol Botol 2
27 DETTOL SOAP FRESH 105GR Pcs Pcs 3
28 DUREX EXTRA SAFE KONDOM@12 Pcs Pcs 1
29 DUREX FETHERLITE KONDOM@12 Pcs Pcs 4
30 DUREX LOVE KONDOM@12 Pcs Pcs 1
32 KY JELLY PERSONAL 100GR Pcs Pcs 2
33 STREPSIL HONEY LEMON@12 Pcs Pcs 8
34 STREPSIL REG@ 12 Pcs Pcs 10
No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 0331-326716
1 ASAM MEFENAMAT 500MG TAB Tablet Box 3

2 CEFIXIME 100MG CAP@50 GDX Kapsul Box 1
3 CEFIXIME 200MG CAP@100 GDX Kapsul Box 1
5 METHYL PREDNISOLON 4MG GDX Tablet Box 1
6 METHYL PREDNISOLON 16MG GDX Tablet Box 1
7 CAPTOPRIL 50MG TAB@100 GDX Tablet Box 1

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017

Telp : 031-3821110
1 HOT IN CR AROMATHERAPY 120ML Pcs Pcs 3

2 HOT IN CR TUBE AROMATHERAPY 60 Pcs Pcs 3
4 HOT IN CR TUBE AROMATHERAPY120 Pcs Pcs 3
5 HOT IN CR AROMATHERAPY 60ML Pcs Pcs 3
6 HOT IN CREAM BTL 60ML Pcs Pcs 3
7 HOT IN CREAM PUMP 120ML Pcs Pcs 3
8 PAGODA SALEP EXTRA 10GR Pcs Pcs 4
10 TUNTAS CAPLET@10 Tablet Box 1
11 NEO ULTRACYCLINE CREAM @ 5 GR Tube Tube 4
12 ERLAMYCETIN EAR DROPS 1% Pcs Pcs 4
13 VIPCOL SYR 60ML Botol Botol 8
15 THROMBOGEL 10GR Tube Tube 3
16 SPASMINAL TAB@100 Tablet Box 1
17 2-4 ZALF 15GR CITO Pcs Pcs 12
18 AMBEVEN KAPSULS Kapsul Box 4
19 LASERIN SYR 110ML Botol Botol 3
22 TIGER BALM RED 20GR Pcs Pcs 1
23 MYCORAL CR 5GR Tube Tube 4

No. Izin Sarana : 503.445/26/429.113/2017
Banyuwangi,

440/2329/SIPA/429.114/II/2017
No. SP : 018/VIII/2019

Nama : Haris Raudhatuzakinah,S.Farm,Apt
Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
1 Aerius D-12 Tablet Pseudoefedrin Sulfat Tablet, 120 mg Box

2 Clarinase Tab 50s Pseudoefedrin Sulfat Tablet, 120 mg Box
3 Telfast Plus Pseudoefedrin HCl Tablet, 120 mg Box
4 Cafergot 100 mg Ergotamin tartrat Tablet, 1 mg Box
5 OBH Combi Batuk Flu Jahe Syr 100ml Efedrin HCl Sirup, 2.5 mg Botol
7 OBH Combi Batuk Flu Madu Syr 100 ml Efedrin HCl Sirup, 2.5 mg Botol
9 OBH Combi Batuk Flu Menthol Syr 100 ml Efedrin HCl Sirup, 2.5 mg Botol
11 OBH Combi Batuk Flu Anak Apel Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
12 OBH Combi Batuk Flu Anak Madu Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
13 OBH Combi Batuk Flu Anak Strawberry Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
14 OBH Combi Batuk Flu Anak Jeruk Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
15 Tusapress Elixir Efedrin HCl Sirup, 12.5 mg Botol
16 Neo Triaminic Drop Pseudoefedrin HCl Drop, 7.5 mg Botol
17 Triaminic Batuk & Pilek Pseudoefedrin HCl Sirup, 15 mg Botol
18 triaminic Pilek Pseudoefedrin HCl Sirup, 15 mg Botol
19 Triaminic Exp & Pilek Pseudoefedrin HCl Sirup, 15 mg Botol
20 Stop Cold Dragee Pseudoefedrin HCl Tablet, 30 mg Box 2
21 Allerin Exp Syr 120 ml Pseudoefedrin HCl Sirup, 15 mg Botol 8
24 Decolsin Syr Pseudoefedrin HCl Sirup, 15 mg Botol 8
25 Paratusin Tab Phenylpropanolamine Tablet, 12.5 mg Box
27 Decolgen PSE Liq Pseudoefedrin HCl Sirup, 7.5 mg Botol
28 Decolgen FX Pseudoefedrin HCl Tablet, 30 mg Box 1
29 Decolgen Tab Phenylpropanolamine Tablet, 12.5 mg Box
30 Asmasolon Tab Efedrin HCl Tablet, 12.5 mg Box
31 Nalgestan Tab Phenylpropanolamine Tablet, 15 mg Box
32 Neozep Forte Tab Blister Phenylpropanolamine Tablet, 12.5 mg Box
33 Neozep Forte Tab Phenylpropanolamine Tablet, 15 mg Box
37 Actifed Syr 120 ml Pseudoefedrin HCl Sirup, 30 mg Botol
39 Actifed Plus Cough Suppresant Syr 120 ml Pseudoefedrin HCl Sirup, 30 mg Botol
41 Actifed Plus Expectorant Syr 120 ml Pseudoefedrin HCl Sirup, 30 mg Botol
43 Panadol Cold & Flu 100s Pseudoefedrin HCl Kaplet, 30 mg Box

Alamat Lengkap : JL GAJAH MADA NO.171 JEMBER
No. Izin Sarana : 503/A.1/SIA/0011.Pb/35.09.325/2018
JEMBER.
Haris Raudhatuzakinah,S.Farm,Apt
SIPA:0038.B/3509325/2018
jo
No. SP : / /

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-335000
Nama Obat
Bentuk
No Mengandung Zat Aktif Prekursor Farmasi Satuan Jumlah
Sediaan
Prekursor Farmasi
1 Mixagrip Flu Phenylpropanolamin 25 Mg Tablet Box
2 Procold Tab Pseudoefedrin 30 mg Tablet Box
DMP 10 mg
3 Mixadin Tablet Box
Efedrin 12,5
4 Promedex Tab Dextromethorphan HBr Tablet Box
5 Anadex Drage DMP, Phenylpropanolamin Kapsul Box
Anadex Syr 60 ml DMP, Phenylpropanolamin Sirup Botol
6
Alco oral drop 15 ml Pseudoefedrin HCl 30 Mg Sirup Botol
7 Alco Plus Sirup Pseudoefedrin HCl Sirup Botol
8 Alco Plus DMP Sirup Pseudoefedrin HCl Sirup Botol
9 Trifed Tablet Pseudoefedrin HCl Tablet Box
10 Trifed Sirup Pseudoefedrin HCl Sirup Botol
JEMBER.
SIPA:0038.B/3509325/2018

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-335000
Nama Obat Mengandung OOT Bentuk

Farmasi Sediaan
1 Wood Sirup Merah / Antitusif 60 ml Dextromethorphan HBr sirup botol

2 Wood Sirup Merah / Antitusif 100 ml Dextromethorphan HBr sirup botol
3 Mextril Sirup Merah / Antitusif Dextromethorphan HBr sirup botol
4 Mextril Batuk Tablet Dextromethorphan HBr tablet box
5 Komix Kids Strawberry Pack Dextromethorphan HBr sirup box
6 Komix Pippermint box Dextromethorphan HBr sirup box
7 Komix Jeruk Nipis box Dextromethorphan HBr sirup box
8 Komix Jahe box Dextromethorphan HBr sirup box
9 Procold Flu dan Batuk PE Tablet Dextromethorphan HBr tablet box
10 Procold Flu dan Batuk Dextromethorphan HBr tablet box
11 Mixagrip Flu dan Batuk PE Tablet Dextromethorphan HBr tablet box

JEMBER.
SIPA:0038.B/3509325/2018

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-324717

OOT Farmasi Sediaan
1 Arkine 2 mg Trihexyphenidil 2 mg Kaplet Box 5

2 Haloperidol 5 mg Haloperidol 5 mg Tablet Box -
3 Patral Tramadol HCl 37.5 Mg Kaplet Box -
4 Tramadol 50 mg Tramadol HCl 50 Mg Kapsul Box -
5 Hexymer 2 mg Trihexyphenidil 2 mg Tablet Box -
6 Merlopam 2 mg Lorazepam 2 mg Tablet Box -
7 Risperidone 2 mg Risperidone 2 mg Tablet Box -
8 Bamgetol Carbamazepin 200 mg Tablet Box -
9 Hufagrip BP Sirup Botol -
Pseudoefedrin 15 mg

JEMBER.
SIPA:0038.B/3509325/2018
No. SP :

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF : PT. Lenko Surya Perkasa
Alamat : Rambipuji
Telp : 082338858388

No Satuan Jumlah
1 OBH Nellco Special 100ml Jahe Ephedrine HCl Sirup Botol 6
2 OBH Nellco Special 100ml Madu Ephedrine HCl Sirup Botol 6
3 OBH Nellco Special 100ml Menthol Ephedrine HCl Sirup Botol 6
4 OBH Nellco Special 100ml Anak Jeruk Ephedrine HCl Sirup Sirup 6
5 OBH Nellco Special 100ml Anak Straw Ephedrine HCl Sirup Sirup 6

JEMBER.
SIPA:0038.B/3509325/2018

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-428184

2 BETAHISTINE TAB @ 30 ( GNV ) Tablet Box 20
3 BISOPROLOL 5 MG TAB (NOVELL) Tablet Box 2
6 CEFIXIME 200MG CAP@50 GNV Kapsul Box 4
7 DOMPERIDONE 10MG TAB@50 GNOV Tablet Box 15
8 GABAPENTIN 300MG CAP@100 GNV Kapsul Box 30
9
10
11
12
13
14
15
16
17
18

JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-428184

4 REGROU FORTE SOL 30ML Pcs Pcs 3
5 REGROU 2% TOP SOL30ML Pcs Pcs 3
8 DESOLEX CREAM Tube Tube 3
9 DESOLEX LOT 30ML Tube Tube 3
11 PARASOL SPF33 CR 20GR Tube Tube 4
15 ATORVASTATIN 20MG TAB GNV Tablet Box 2
16
17
18

JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF :
Alamat :
Telp :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF :
Alamat :
Telp :
1 antasida sirup karton 1

2 betametason salep dus 1
3 betason n dus 1
4 antihemoroid suppo box 2
5 enervon c @30 botol 3
6 dexocort box 2
7 chloramfecort h box 1
8 chloramfecort box 1
9 heplav box 2
10 ricovir box 2
11 glimepiride 2mg box 10
12 glyceril guaiacolat box 2
13 magasida 60ml botol 24
14 magasida 120ml botol 24
15 pyrantel box 1
16 rahistin box 5
17 statcol 10mg box 3
18 statcol 20mg box 3
19 asam folat box 3
20 betadin vaginal douche ta pc 3
JEMBER.
SIPA:0038.B/3509325/2018

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF :
Alamat :
Telp :
1 betadin vaginal douche pa pc 3

2 NAN PHPRO 1 400 gr pc 4
3 NAN PHPRO 1 400 gr pc 4
4 NAN Lactose Free 400 gr pc 4
5 bear brand gold teh putih dus 2
6 bear brand rtd milk dus 1
7 bear brand gold malt putih dus 1
8 mecobalamin inj box 1
9 phenytoin inj box 1
10 ondansetron 8mg inj box 1
11
12
13
14
15
16
17
18
19
20
JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF :
Alamat :
Telp :
1 cendo tobro ed 5
2 cendo tobroson md 3
3 cendo voitrolenta ed 5
4 aspilet 3
5 burnazin 5
6 moloco b 12 1
7 natur-e day cream 4
8 natur-e night cream 4
9 natur-e advan serum 15 ml 6
10 natur-e NR 100 ml lotion 6
11 natur-e NR 200 ml lotion 3
12 you c 1000 lemon 24
13 you c 1000 orange 24
14 you c 1000 lemon water 12
15 you c 1000 orange water 12
16 new diatab 3
17 salep2-4 12
18 kasa hydr steril 16X16 24
19 kasa pembalut 4x10 30
20 kasa pembalut 4x15 30
JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-428184
1 IRBESARTAN 300MG@20 GNV Tablet Box 20

2 AMLOCOR 5MG Tablet Box 5
3 PROHYTENS 10 MG Tablet Box 2
4 LISINOPRIL TAB 5MG Tablet Box 1
5 NOTISIL 2MG Tablet Box 20
6
7
8
9
10
11
12
13
14
15
16
17
18

JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt
No. SP : 003/VI/2018

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF : Sakajaya
Alamat :
Telp :

No Zat Aktif Prekursor Farmasi Satuan
Farmasi Sediaan
18 Triaminic Pilek Pseudoefedrin HCl Sirup, 15 mg Botol

JEMBER.
Haris Raudhatuzakinah,S.Farm,Ap
SIPA:0038.B/3509325/2018
ASI
Jumlah
6
10
0
10
10
10
10
nanggung jawab
atuzakinah,S.Farm,Ap
09325/2018

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF : Enseval
Alamat :Jember
Telp

1 BMT gold 200 gr 5
2 Dsol sweet stevia 50X2GR 1
3 Morinaga NL-33 GR 1

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 011/VII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
2 triaminic Pilek Pseudoefedrin HCl Sirup, 15 mg Botol 20
4 Actifed Syr 60 ml Pseudoefedrin HCl Sirup, 30 mg Botol 20

JEMBER.
SIPA:0038.B/3509325/2018
: Anugrah Pharmindo Lestari
: Jl. Berbek industri I No.1 Kav A-C Waru Sidoarjo
: 031-8439839
No. SP : 019/07/2019

Nama : Elly Febry Taufany, S.Farm., Apt.
Nomor SIPA : 503/A.1/SIPA/0052.B/35.09.325/2018
Nama PBF : Anugrah Argon Medika
Telp : 0331-326717
Nama Obat Mengandung Bentuk Sediaan dan Jumlah(angka

No
Prekursor Farmasi Kekuatan/Potensi Kemasan Satuan &huruf)
1 Rhinofed Tablet Tablet, 30 mg Tablet Box 0 (nol)
2 Rhinofed Suspensi 60 ml Suspensi, 15 mg/5ml Botol Botol 0 (nol)
3 Rhinos SR Kapsul Lepas Lambat 120 mg Kapsul Box 0 (nol)
4 Rhinos Junior Syrup 60 ml Syrup, 15 mg/ 5 ml Botol Botol 10 (sepuluh)
5 Rhinos Neo Drop Larutan, 7.5 mg/0.8 ml Botol Botol 15 (lima belas)
6
7

Nama Sarana : Apotek Kimia Farma Talangsari
Alamat Lengkap : JL. K. h shiddiq no 39A_B
No. Izin Sarana : 503/A.1/SIA/0020.B/35.09.325/2018
JEMBER,
: Elly Febry Taufany, S.Farm., Apt.

: 503/A.1/SIPA/0052.B/35.09.325/2018
wab
arm., Apt.
5.09.325/2018
No. SP : 011/VII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah

JEMBER.
SIPA:0038.B/3509325/2018
arjo
No. SP : 012/VII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
7 OBH Combi Batuk Flu Anak Madu Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol 12
8 OBH Combi Batuk Flu Anak Strawberry Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol 12
9 Panadol Cold & Flu 100s Pseudoefedrin HCl Kaplet, 30 mg Box 2

JEMBER.
SIPA:0038.B/3509325/2018
arjo
No. SP : 008/VIII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF : Kebayoran
Alamat : Jalan Nusantara V No. 12A Blok C Jember
Telp : 0331-423743

1 Zolmia 10mg tab Zolpidem Tartrate Tablet Box/30 3

2
3
4
5

JEMBER.
SIPA:0038.B/3509325/2018
SURAT PEMESANAN OBAT MENGANDUNG OOT FARMASI
No. SP : 018/VIII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-428184

OOT Farmasi Sediaan
1 Arkine tab Trihexyphenidyl 2 mg Tablet Box 30

2
3
4
5

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 012/VIII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-324717

OOT Farmasi Sediaan
1 Merlopam 0.5 mg Lorazepam 0.5 mg Tablet Dus 3

2
3
4
5

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 013/VIII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-324717

OOT Farmasi Sediaan
1 Merlopam 2 mg Lorazepam 2 mg Tablet Dus 3

2
3
4
5

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 015/VIII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-421675

OOT Farmasi Sediaan
1 Chlorpromazin 100 mg Chlorpromazin 100 mg tablet box 20

2
3
4
5

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : / / 2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF :
Alamat :
Telp :

OOT Farmasi Sediaan
1
2
3
4
5
6
7
8
9
10

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 018/VIII/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
1 Stop Cold Dragee Pseudoefedrin HCl Tablet, 30 mg Box 2
7 Decolgen FX Pseudoefedrin HCl Tablet, 30 mg Box 1

JEMBER.
SIPA:0038.B/3509325/2018
jo

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-421675
1 Domperidon tab Tablet Box 6

2 Cotrimoxsazole tab Tablet Box 2
3 Glimepiride 2mg tab Tablet Box 10
4 Hydrocortison 2.5% cr Tube Box 2
5 Betamethasone cr Tube Box 5
6 Cotrimoxsazole Syr Botol Botol 8
7 Kamaflam 50mg tab Tablet Box 10
8 Ketoconazole Tube Box 2
9
10
11
12
13
14
15
16
17

JEMBER.
SIPA:0038.B/3509325/2018
ab
arm,Apt
8

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-428184
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

JEMBER.
SIPA:0038.B/3509325/2018
b
rm,Apt

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 0331-326716
1 HERBAKOF 60 ml Botol Botol 6

2 STIMUNO FORTE CAP Kapsul Box 10
3 STIMUNO SYRUP 100ML Botol Botol 6
4 STIMUNO SYRUP 60ML Botol Botol 6
5 STIMUNO SYRUP GRAPE 100ML Botol Botol 6
6 STIMUNO SYRUP GRAPE 60ML Botol Botol 6
7 STIMUNO SYRUP ORANGE BERRY 60ML Botol Botol 6
8 VOLTADEX GEL 1% Tube Tube 3

JEMBER.
SIPA:0038.B/3509325/2018
b
arm,Apt
8
No. SP : 028/IX/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
5 Triaminic Pilek Pseudoefedrin HCl Sirup, 15 mg Botol -
7 Panadol Cold & Flu 100s Pseudoefedrin HCl Kaplet, 30 mg Box 2

JEMBER.
SIPA:0038.B/3509325/2018
arjo
No. SP : 029/IX/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
1 Panadol Flu Batuk Phenylephrine Tablet, 30 mg Box 2

JEMBER.
SIPA:0038.B/3509325/2018
arjo
No. SP : 004/X/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
4 Decolgen Tab Phenylpropanolamine Tablet, 12.5 mg Box 3
5 Asmasolon Tab Efedrin HCl Tablet, 12.5 mg Box 2
6 Neozep Forte Tab Phenylpropanolamine Tablet, 15 mg Box 3

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 005/X/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
1 Aerius D-12 Tablet Pseudoefedrin Sulfat Tablet, 120 mg Box

2 Clarinase Tab 50s Pseudoefedrin Sulfat Tablet, 120 mg Box
3 Telfast Plus Pseudoefedrin HCl Tablet, 120 mg Box
4 Cafergot 100 mg Ergotamin tartrat Tablet, 1 mg Box
11 OBH Combi Batuk Flu Anak Apel Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
12 OBH Combi Batuk Flu Anak Madu Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
13 OBH Combi Batuk Flu Anak Strawberry Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
14 OBH Combi Batuk Flu Anak Jeruk Syr Pseudoefedrin HCl Sirup, 7.5 mg Botol
15 Tusapress Elixir Efedrin HCl Sirup, 12.5 mg Botol
18 triaminic Pilek Pseudoefedrin HCl Sirup, 15 mg Botol
20 Stop Cold Dragee Pseudoefedrin HCl Tablet, 30 mg Box
21 Allerin Exp Syr 120 ml Pseudoefedrin HCl Sirup, 15 mg Botol
22 Allerin Exp Syr 60 ml Pseudoefedrin HCl Sirup, 15 mg Botol
23 Decolsin Caps Phenylpropanolamine Kapsul, 12.5 mg Box
24 Decolsin Syr Pseudoefedrin HCl Sirup, 15 mg Botol
25 Paratusin Tab Phenylpropanolamine Tablet, 12.5 mg Box
26 Paratusin Syr Pseudoefedrin HCl Sirup, 15 mg Botol
27 Decolgen PSE Liq Pseudoefedrin HCl Sirup, 7.5 mg Botol
28 Decolgen FX Pseudoefedrin HCl Tablet, 30 mg Box
29 Decolgen Tab Phenylpropanolamine Tablet, 12.5 mg Box
30 Asmasolon Tab Efedrin HCl Tablet, 12.5 mg Box
31 Nalgestan Tab Phenylpropanolamine Tablet, 15 mg Box
32 Neozep Forte Tab Blister Phenylpropanolamine Tablet, 12.5 mg Box
33 Neozep Forte Tab Phenylpropanolamine Tablet, 15 mg Box
43 Panadol Cold & Flu 100s Pseudoefedrin HCl Kaplet, 30 mg Box

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : 005/X/2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Telp : 031-8439839

No Satuan Jumlah
5 Decolgen Tab Phenylpropanolamine Tablet, 12.5 mg Box 3

JEMBER.
SIPA:0038.B/3509325/2018
No. SP : / / 2019

Nomor SIPA : SIPA:0038.B/3509325/2018
Nama PBF :
Alamat :
Telp :

No Satuan Jumlah
1
2
3
4
5
6
7
8
9
10

JEMBER.
SIPA:0038.B/3509325/2018

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1 Asthma Soho Ephedrine 12,5 mg Tab Dus 3

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1 Nasafed Syr 60 Ml Pseudoefedrin 15 mg Sirup Botol -

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1 Arkine 2 mg Trihexyphenidil 2 mg Kaplet Dus -

Obat tersebut akan digunakan untuk memenuhi kebutuhan Apotek :

Ditha Violy Nindyasari,S.Farm.,Apt.

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1 Bodrexin Flu & Batuk Syr 56ml Sirup Botol 25

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Bayu Herdi Al Huda, Apt

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1 Termorex Plus 30 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 3

2 Termorex Plus 60 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol 7

3 Anakonidin 30 ml Pseudoephedrin HCl 7.5 mg/ 5 ml Botol -

Ditha Violy Nindyasari,S.Farm.,Apt.

Yang bertanda tangan di bawah ini :

Nama Obat Mengandung Prekursor Bentuk

Obat tersebut akan digunakan untuk memenuhi kebutuhan Apotek :

Ditha Violy Nindyasari,S.Farm.,Apt

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1 Tradosik 50 MG Cap Tramadol HCL 50 Mg Tab Dus 2

Obat tersebut akan digunakan untuk memenuhi kebutuhan Apotek :

Bayu Herdi Al Huda, Apt

Yang bertanda tangan di bawah ini :

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Obat tersebut akan digunakan untuk memenuhi kebutuhan Apotek :

Ditha Violy Nindyasari,S.Farm.,Apt

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Ditha Violy Nindyasari,S.Farm.,Apt.

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1 Aerius D-12 Tablet Pseudoefedrin Sulfat Tablet, 120 mg Box -

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Ditha Violy Ninidyasari,S.Farm.,Apt

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1 Analtram Tramadol HCl 37.5 mg Tablet Dus 3

Obat tersebut akan digunakan untuk memenuhi kebutuhan Apotek :

Bayu Herdi Al Huda, Apt

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No Nama Obat Bentuk Sediaan Satuan Jumlah