14D2000588 CLIA NUMBER - KROGER PHARMACY L-711 THE KROGER COMPANY

Laboratory Demographics

  • CLIA Code: 14D2000588
  • Facility Name: KROGER PHARMACY L-711 THE KROGER COMPANY
  • Facility Address: 415 S 42ND ST
    MOUNT VERNON, IL
    ZIP 62864
  • Facility Phone: (618) 244-9660
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: PHELICISIMA ROBERTS
  • NPI Number: 1316971120
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 14D2000588
LAB Type Pharmacy
Facility Name KROGER PHARMACY L-711 THE KROGER COMPANY
Street 415 S 42ND ST
City MOUNT VERNON
State IL
ZIP 62864
Phone 6182449660
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/3/2025
Certificate Expiration Date 12/2/2027
Facility Type Pharmacy
Lab Director PHELICISIMA ROBERTS

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