11D2263192 CLIA NUMBER - AUTRY STATE PRISON

Laboratory Demographics

  • CLIA Code: 11D2263192
  • Facility Name: AUTRY STATE PRISON
  • Facility Address: 3178 MOUNT ZION CHURCH ROAD
    PELHAM, GA
    ZIP 31779
  • Facility Phone: 678 470-3977
  • Facility Type: Prison
  • Facility Type: Waiver
  • Lab Director: MARK WOOD
  • NPI Number: 1831689728
  • Taxonomy: 3336I0012X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 11D2263192
LAB Type Prison
Facility Name AUTRY STATE PRISON
Street 3178 MOUNT ZION CHURCH ROAD
City PELHAM
State GA
ZIP 31779
Phone 678 470-3977
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/24/2024
Certificate Expiration Date 6/23/2026
Facility Type Prison
Lab Director MARK WOOD

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