04D2122878 CLIA NUMBER - SAM'S CLUB PHARMACY 10-4749

Laboratory Demographics

  • CLIA Code: 04D2122878
  • Facility Name: SAM'S CLUB PHARMACY 10-4749
  • Facility Address: 1250 SOUTH AMITY RD
    CONWAY, AR
    ZIP 72032
  • Facility Phone: 479 258-2243
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: ASHLEY JACKSON
  • NPI Number: 1639620099
  • Taxonomy: 332H00000X - Eyewear Supplier

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CLIA Record

Field Name Field Value
CLIA Number 04D2122878
LAB Type Pharmacy
Facility Name SAM'S CLUB PHARMACY 10-4749
Street 1250 SOUTH AMITY RD
City CONWAY
State AR
ZIP 72032
Phone 479 258-2243
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/8/2024
Certificate Expiration Date 12/7/2026
Facility Type Pharmacy
Lab Director ASHLEY JACKSON

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