04D1021880 CLIA NUMBER - KROGER PHARMACY #465

Laboratory Demographics

  • CLIA Code: 04D1021880
  • Facility Name: KROGER PHARMACY #465
  • Facility Address: 400 WEST MOULTRIE
    BLYTHEVILLE, AR
    ZIP 72315
  • Facility Phone: 870 763-7951
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: CYNTHIA B. FISHER
  • NPI Number: 1407880255
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 04D1021880
LAB Type Pharmacy
Facility Name KROGER PHARMACY #465
Street 400 WEST MOULTRIE
City BLYTHEVILLE
State AR
ZIP 72315
Phone 870 763-7951
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/3/2024
Certificate Expiration Date 2/2/2026
Facility Type Pharmacy
Lab Director CYNTHIA B. FISHER

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This page was last updated on: 9/29/2025