05D2226650 CLIA NUMBER - PETRA PHARMACY CORP DBA MEDICINE SHOPPE, THE

Laboratory Demographics

  • CLIA Code: 05D2226650
  • Facility Name: PETRA PHARMACY CORP DBA MEDICINE SHOPPE, THE
  • Facility Address: 1477 SOUTH SAN JACINTO AVE
    SAN JACINTO, CA
    ZIP 92583
  • Facility Phone: 951 654-2791
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: VICK TARR
  • NPI Number: 1104901131
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 05D2226650
LAB Type Pharmacy
Facility Name PETRA PHARMACY CORP DBA MEDICINE SHOPPE, THE
Street 1477 SOUTH SAN JACINTO AVE
City SAN JACINTO
State CA
ZIP 92583
Phone 951 654-2791
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/2/2025
Certificate Expiration Date 6/1/2027
Facility Type Pharmacy
Lab Director VICK TARR

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