14D2015177 CLIA NUMBER - WALGREENS # 04779

Laboratory Demographics

  • CLIA Code: 14D2015177
  • Facility Name: WALGREENS # 04779
  • Facility Address: 1799 DOUGLAS RD
    MONTGOMERY, IL
    ZIP 60538
  • Facility Phone: 630 896-6960
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: JEFFREY R. STACEY
  • NPI Number: 1164437489
  • Taxonomy: 333600000X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 14D2015177
LAB Type Pharmacy
Facility Name WALGREENS # 04779
Street 1799 DOUGLAS RD
City MONTGOMERY
State IL
ZIP 60538
Phone 630 896-6960
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/11/2025
Certificate Expiration Date 5/10/2027
Facility Type Pharmacy
Lab Director JEFFREY R. STACEY

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