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PT.

SEHAT INTI PERKASA


Jl. Rambutan Blok D No 213J-214- 215 RT 25 RW 08
Desa Tambak Sumur Kecamatan Waru Sidoarjo
Telp. 031 - 868 8788 Fax. 031 - 867 8788

Tanggal :
DATA CUSTOMER Marketing :
Baru

Revisi karena ada pergantian PJ/Pindah gudang/


alamat

Customer : ....................................................................................................................

Alamat : ...................................................................................................................

No Tel/HP PJ : ...................................................................................................................

Email : ...................................................................................................................

No Izin PBF/SIA : ...................................................................................................................

No. SIPA : ...................................................................................................................

No. NIB : ...................................................................................................................

Apoteker PJ : ...................................................................................................................

Alamat PJ : ...................................................................................................................

Nama Pemilik : ...................................................................................................................

Alamat Pemilik : ...................................................................................................................

NPWP : ...................................................................................................................

No. CDOB : ...................................................................................................................

Kode Sarana : ...................................................................................................................

Spesimen Spesimen Tanda tangan Spesimen Tanda tangan Spesimen Tanda tangan
Stampel Apoteker Penanggung TTK/Asisten apoteker Penerima barang
Customer Jawab

*Mohon Sertakan Fotocopy SIA, Izin PBF, SIPA,No. NIB, KTP dan NPWP
* Kode Sarana (E-Report/SIPNAP)
*No.CDOB Khusus PBF

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