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FORMULIR PENGAJUAN PENGADAAN OBAT/ BHP/ ALKES

Nama Ruang/Unit : MAJAPAHIT

Tanggal Pengajuan : 16/08/2021

Nama Stok Kebutuhan Pengajuan Harga


No Satuan Total
Barang/Obat/Alkes Awal Jumlah Satuan Jumlah Satuan satuan
1 Acyclovir cream TUBE 7 15 TUBE 8 TUBE 3,000 24,000
2 Acyclovir tab 400 mg TAB 290 6 BOX 2 BOX 31,525 63,050
3 Allopurinol 300 MG TAB 70 1 BOX 1 BOX 42,000 42,000
4 Antasid Syr Flash 20 40 Flash 10 Flash 3,200 32,000
Asam Mefenamat 500
Tab 386 6 Box 1 Box 27,500
5 MG 27,500
6 Betahistin Tab TAB 96 4 BOX 1 BOX 25,200 25,200
7 Cefixim 100 MG Tab 488 25 Box 10 Box 108,845 1,088,450
8 Cetirizine 10 MG TAB 218 6 BOX 3 BOX 17,500 52,500
9 Corovit TAB Tab 0 1 Box 1 Box 81,700 81,700
10 Cyclogeston Inj Vial 0 1 Box 1 Box 69,300 69,300
11 Curcuma STRIP TAB 132 1 BOX 1 BOX 86,730 86,730
12 Damuvit TAB TAB 218 3 BOX 1 BOX 158,000 158,000
13 Dextaco Tab Tab 300 5 Box 2 Box 17,850 35,700
14 Dextral Syr 60 ML Flash 0 15 Flash 15 Flash 9,570 143,550
15 Dextral Tab Tab 0 2 Box 2 Box 79,750 159,500
16 Dolo Licobion TAB 360 5 BOX 1 BOX 96,900 96,900
17 Erla Tetes Telinga FLASH 5 6 FLASH 1 FLASH 7,100 7,100
18 Flutamol P Cap Tab 344 7 Box 3 Box 105,000 315,000
19 Flutamol P Syr FLASH 5 10 FLASH 5 FLASH 9,937 49,685
20 Gitas Inj Amp 11 3 Box 1 Box 128,625 128,625
21 Guanistrep Syr Flash 9 14 Flash 6 Flash 5,200 31,200
Grafazol 500 MG
( METRONIDAZOLE TAB 50 1 BOX 1 BOX 27,000
22 TAB ) 27,000
23 Hexon Tab TAB 28 2 BOX 1 BOX 22,000 22,000
Ibuprofen 400 MG
TAB 230 5 BOX 3 BOX 30,000
24 Tab 90,000
25 Ketorolac Inj AMP 10 2 BOX 1 BOX 98,500 98,500
26 Koligon Tab Tab 106 3 Box 1 Box 140,000 140,000
27 Licodexon 0,5 Tab 560 5 Box 2 Box 26,000 52,000
28 Licodium Tab 200 4 Box 2 Box 18,000 36,000
29 Licogenta Cream Tube 12 26 Tube 10 Tube 4,100 41,000
Meloxicam Tab 7,5
TAB 110 4 BOX 2 BOX 31,450
30 MG 62,900
Methyl Prednisolone
Tab 430 7 Box 2 Box 44,055
31 4 MG 88,110
32 Omedom Syr Flash 12 30 Flash 10 Flash 3,300 33,000
33 Omedom Tablet Tab 520 8 Box 3 Box 16,000 48,000
34 Omeprazole Tab Tab 690 33 Box 10 Box 11,136 111,360
35 Ondansetron Inj 4 MG Amp 10 3 Box 1 Box 35,000 35,000
Ondansetron Tab 4
Tab 170 6 Box 2 Box 77,000
36 MG 154,000
37 Oraprofen Syr FLASH 7 20 FLASH 10 FLASH 3,600 36,000
Paracetamol SYR 60
Flash 3 8 Flash 5 Flash 2,700
38 ML 13,500
39 Ranitidine INJ AMP 12 2 BOX 1 BOX 30,000 30,000
40 Reco TM FLASH 4 6 FLASH 2 FLASH 8,500 17,000
41 Silopect Tab 280 4 Box 1 Box 95,000 95,000
1
42 Solathim SYR FLASH 1 5 FLASH 4 FLASH 6,800 27,200
43 Spasminal Tab 300 5 Box 2 Box 56,700 113,400
44 Stomach Tab Tab 434 7 Box 2 Box 13,500 27,000
45 Tes Hamil Flash 3 9 Flash 5 Flash 16,800 84,000
46 ZINC TAB TAB 74 3 BOX 2 BOX 61,500 123,000
47 Alkohol One Swab Box 1 2 Box 1 Box 35,715 35,715
48 Aseptan 500 ML Flash 3 5 Flash 2 Flash 71,429 142,858
49 Bisturi PCS 2 5 PCS 3 PCS 3,000 9,000
Jarum Mani SE ME
PCS 1 5 PCS 4 PCS 14,881
50 NO. 21 59,524
51 Masker KN95 Pak 1 4 Pak 3 Pak 0 -
52 Needle 23G Pcs 10 30 Pcs 20 Pcs 643 12,860
Sarung Tangan
Box 1 2 Box 1 Box 74,300
53 ukuran M 74,300
54 Stik GDS BOX 1 2 BOX 1 BOX 150,000 150,000
55 Stik Kolesterol BOX 1 2 BOX 1 BOX 257,140 257,140
  JUMLAH 4,527,867

Semarang, 15/08/2021

Bagian Pembelian Pemohon

(Endang Rodaningsih) (Riestha R S)

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