04D2138568 CLIA NUMBER - WAGNER'S MOUNT IDA PHARMACY

Laboratory Demographics

  • CLIA Code: 04D2138568
  • Facility Name: WAGNER'S MOUNT IDA PHARMACY
  • Facility Address: 744 HWY 270EAST
    MOUNT IDA, AR
    ZIP 71957
  • Facility Phone: 870 867-3174
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: MS. LAURA WAGNER
  • NPI Number: 1568477198
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 04D2138568
LAB Type Pharmacy
Facility Name WAGNER'S MOUNT IDA PHARMACY
Street 744 HWY 270EAST
City MOUNT IDA
State AR
ZIP 71957
Phone 870 867-3174
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/20/2023
Certificate Expiration Date 10/19/2025
Facility Type Pharmacy
Lab Director MS. LAURA WAGNER

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This page was last updated on: 3/20/2025