04D1021894 CLIA NUMBER - KROGER PHARMACY #624

Laboratory Demographics

  • CLIA Code: 04D1021894
  • Facility Name: KROGER PHARMACY #624
  • Facility Address: 1003 WEST MAIN ST
    RUSSELLVILLE, AR
    ZIP 72801
  • Facility Phone: 479 880-1877
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: CYNTHIA B. FISHER
  • NPI Number: 1316971161
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 04D1021894
LAB Type Pharmacy
Facility Name KROGER PHARMACY #624
Street 1003 WEST MAIN ST
City RUSSELLVILLE
State AR
ZIP 72801
Phone 479 880-1877
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