11D2282541 CLIA NUMBER - GEORGIA CVS PHARMACY, LLC DBA CVS/PHARMACY #04709

Laboratory Demographics

  • CLIA Code: 11D2282541
  • Facility Name: GEORGIA CVS PHARMACY, LLC DBA CVS/PHARMACY #04709
  • Facility Address: 77 HUDSON PLAZA
    FAIRBURN, GA
    ZIP 30213
  • Facility Phone: (770) 964-7167
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: EMMANUEL ANTWI BOASIAKO
  • NPI Number: 1629171475
  • Taxonomy: 333600000X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 11D2282541
LAB Type Pharmacy
Facility Name GEORGIA CVS PHARMACY, LLC DBA CVS/PHARMACY #04709
Street 77 HUDSON PLAZA
City FAIRBURN
State GA
ZIP 30213
Phone 7709647167
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/23/2025
Certificate Expiration Date 5/22/2027
Facility Type Pharmacy
Lab Director EMMANUEL ANTWI BOASIAKO

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This page was last updated on: 5/18/2026