11D2140576 CLIA NUMBER - KROGER PHARMACY #457

Laboratory Demographics

  • CLIA Code: 11D2140576
  • Facility Name: KROGER PHARMACY #457
  • Facility Address: 2700 BRASELTON HIGHWAY
    DACULA, GA
    ZIP 30019
  • Facility Phone: 770 614-1022
  • Facility Type: Other - RETAIL PHARMACY
  • Facility Type: Waiver
  • Lab Director: CHUCK PAGE
  • NPI Number: 1376577114
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 11D2140576
LAB Type Other - RETAIL PHARMACY
Facility Name KROGER PHARMACY #457
Street 2700 BRASELTON HIGHWAY
City DACULA
State GA
ZIP 30019
Phone 770 614-1022
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/27/2023
Certificate Expiration Date 11/26/2025
Facility Type Other - RETAIL PHARMACY
Lab Director CHUCK PAGE

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