11D2034607 CLIA NUMBER - WALGREENS 05954

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Laboratory Demographics

CLIA Number: 11D2034607

Facility Name: WALGREENS 05954

Facility Address:
1247 WALNUT AVENUE, WEST
DALTON, GA
ZIP 30720
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Facility Phone Number: 706 428-9003

Facility Type: Pharmacy

Certificate Type: Waiver

NPI Number: 1235441494

Taxonomy: 305S00000X - Point of Service
This product may also be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enrolled in an HMO but have the option to go outside the networks for an additional cost.

CLIA Record

Field Name	Field Value
CLIA Number	11D2034607
LAB Type	Pharmacy
Facility Name	WALGREENS 05954
Street	1247 WALNUT AVENUE, WEST
City	DALTON
State	GA
ZIP	30720
Phone	706 428-9003
CertificateType	4
CertificateEffectiveDate	8/10/2023
CertificateExpirationDate	8/9/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024