14D2015185 CLIA NUMBER - WALGREENS #04832

Laboratory Demographics

  • CLIA Code: 14D2015185
  • Facility Name: WALGREENS #04832
  • Facility Address: 6505 N ILLINOIS ST
    FAIRVIEW HEIGHTS, IL
    ZIP 62208
  • Facility Phone: 618 394-8744
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: KELLY A. ODUM
  • NPI Number: 1568742211
  • Taxonomy: 302R00000X - Health Maintenance Organization

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CLIA Record

Field Name Field Value
CLIA Number 14D2015185
LAB Type Pharmacy
Facility Name WALGREENS #04832
Street 6505 N ILLINOIS ST
City FAIRVIEW HEIGHTS
State IL
ZIP 62208
Phone 618 394-8744
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/28/2023
Certificate Expiration Date 10/27/2025
Facility Type Pharmacy
Lab Director KELLY A. ODUM

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