14D2202682 CLIA NUMBER - PETERSBURG PHARMACY

Laboratory Demographics

  • CLIA Code: 14D2202682
  • Facility Name: PETERSBURG PHARMACY
  • Facility Address: 1 CENTRE DRIVE STE 100
    PETERSBURG, IL
    ZIP 62675
  • Facility Phone: 217 632-7777
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: DAVID M. BAGOT
  • NPI Number: 1538259403
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 14D2202682
LAB Type Pharmacy
Facility Name PETERSBURG PHARMACY
Street 1 CENTRE DRIVE STE 100
City PETERSBURG
State IL
ZIP 62675
Phone 217 632-7777
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/30/2024
Certificate Expiration Date 11/29/2026
Facility Type Pharmacy
Lab Director DAVID M. BAGOT

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