11D2175311 CLIA NUMBER - WALMART PAHRMACY 10-864

Laboratory Demographics

  • CLIA Code: 11D2175311
  • Facility Name: WALMART PAHRMACY 10-864
  • Facility Address: 3109 E 1ST STREET
    VIDALIA, GA
    ZIP 30474
  • Facility Phone: 912 537-7765
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: GREGG BRANDUSH
  • NPI Number: 1588681993
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 11D2175311
LAB Type Pharmacy
Facility Name WALMART PAHRMACY 10-864
Street 3109 E 1ST STREET
City VIDALIA
State GA
ZIP 30474
Phone 912 537-7765
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/19/2023
Certificate Expiration Date 11/18/2025
Facility Type Pharmacy
Lab Director GREGG BRANDUSH

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