13D2149956 CLIA NUMBER - WALMART SUPERCENTER

Laboratory Demographics

  • CLIA Code: 13D2149956
  • Facility Name: WALMART SUPERCENTER
  • Facility Address: 565 JENSEN GROVE DR
    BLACKFOOT, ID
    ZIP 83221
  • Facility Phone: 208 785-0277
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: CHEYENE J. NICKERSON
  • NPI Number: 1801813159
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 13D2149956
LAB Type Pharmacy
Facility Name WALMART SUPERCENTER
Street 565 JENSEN GROVE DR
City BLACKFOOT
State ID
ZIP 83221
Phone 208 785-0277
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/14/2024
Certificate Expiration Date 6/13/2026
Facility Type Pharmacy
Lab Director CHEYENE J. NICKERSON

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This page was last updated on: 6/4/2025