04D2126175 CLIA NUMBER - SAM'S CLUB PHARMACY 10-4969 SAM'S WEST, INC

Laboratory Demographics

  • CLIA Code: 04D2126175
  • Facility Name: SAM'S CLUB PHARMACY 10-4969 SAM'S WEST, INC
  • Facility Address: 3500 SE CLUB BLVD
    BENTONVILLE, AR
    ZIP 72712
  • Facility Phone: 479 621-0283
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: MS. SEAN SULLIVAN
  • NPI Number: 1841376035
  • Taxonomy: 332H00000X - Eyewear Supplier

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CLIA Record

Field Name Field Value
CLIA Number 04D2126175
LAB Type Pharmacy
Facility Name SAM'S CLUB PHARMACY 10-4969 SAM'S WEST, INC
Street 3500 SE CLUB BLVD
City BENTONVILLE
State AR
ZIP 72712
Phone 479 621-0283
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/21/2025
Certificate Expiration Date 2/20/2027
Facility Type Pharmacy
Lab Director MS. SEAN SULLIVAN

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