14D2133004 CLIA NUMBER - SAM'S CLUB PHARMACY 10-8128

Laboratory Demographics

  • CLIA Code: 14D2133004
  • Facility Name: SAM'S CLUB PHARMACY 10-8128
  • Facility Address: 4100 W WILLOW KNOLLS DR
    PEORIA, IL
    ZIP 61615
  • Facility Phone: 309 692-1508
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: JUSTIN L. VADUKUMCHERRY
  • NPI Number: 1225125925
  • Taxonomy: 332H00000X - Eyewear Supplier

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CLIA Record

Field Name Field Value
CLIA Number 14D2133004
LAB Type Pharmacy
Facility Name SAM'S CLUB PHARMACY 10-8128
Street 4100 W WILLOW KNOLLS DR
City PEORIA
State IL
ZIP 61615
Phone 309 692-1508
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 7/3/2025
Certificate Expiration Date 7/2/2027
Facility Type Pharmacy
Lab Director JUSTIN L. VADUKUMCHERRY

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