04D2139512 CLIA NUMBER - WALMART PHARMACY 10-5737

Laboratory Demographics

  • CLIA Code: 04D2139512
  • Facility Name: WALMART PHARMACY 10-5737
  • Facility Address: 3475 W BLACK FOREST DRIVE
    FAYETTEVILLE, AR
    ZIP 72704
  • Facility Phone: 479 442-2276
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: MR. BAILEE BRANDT
  • NPI Number: 1780973693
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 04D2139512
LAB Type Pharmacy
Facility Name WALMART PHARMACY 10-5737
Street 3475 W BLACK FOREST DRIVE
City FAYETTEVILLE
State AR
ZIP 72704
Phone 479 442-2276
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/6/2023
Certificate Expiration Date 11/5/2025
Facility Type Pharmacy
Lab Director MR. BAILEE BRANDT

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