14D1055047 CLIA NUMBER - CUB PHARMACY #1625 SUPERVALU PHARMACIES, INC

Laboratory Demographics

  • CLIA Code: 14D1055047
  • Facility Name: CUB PHARMACY #1625 SUPERVALU PHARMACIES, INC
  • Facility Address: 1512 S WEST AVE
    FREEPORT, IL
    ZIP 61032
  • Facility Phone: 815 297-0881
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: DOMINQUE WEBB
  • NPI Number: 1538274667
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 14D1055047
LAB Type Pharmacy
Facility Name CUB PHARMACY #1625 SUPERVALU PHARMACIES, INC
Street 1512 S WEST AVE
City FREEPORT
State IL
ZIP 61032
Phone 815 297-0881
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/7/2024
Certificate Expiration Date 6/6/2026
Facility Type Pharmacy
Lab Director DOMINQUE WEBB

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