Brand Name | INPEN MMT-105ELBLNA ELI LILY BLUE |
Type of Device | SYRINGE, PISTON |
Manufacturer (Section D) |
COMPANION MEDICAL INC |
1223 world trade drive, 100 |
san diego CA 92128 |
|
Manufacturer (Section G) |
COMPANION MEDICAL INC |
1223 world trade drive, 100 |
|
san diego CA 92128 |
|
Manufacturer Contact |
tricha
miles
|
1223 world trade drive, 100 |
san diego, CA 92128
|
7635140379
|
|
MDR Report Key | 12356581 |
MDR Text Key | 268920633 |
Report Number | 3012822846-2021-00669 |
Device Sequence Number | 1 |
Product Code |
FMF
|
UDI-Device Identifier | 0000108620880003 |
UDI-Public | (01)0000108620880003(10)B93TG |
Combination Product (y/n) | N |
Reporter Country Code | US |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
consumer |
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
08/23/2021 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Lay User/Patient
|
Device Model Number | MMT-105ELBLNA |
Device Catalogue Number | MMT-105ELBLNA |
Device Lot Number | B93TG |
Was Device Available for Evaluation? |
No
|
Initial Date Manufacturer Received |
08/19/2021 |
Initial Date FDA Received | 08/23/2021 |
Was Device Evaluated by Manufacturer? |
No
|
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Unknown
|
Patient Sequence Number | 1 |
Patient Age | 36 YR |
Patient Weight | 179 |
|
|