15D1034680 CLIA NUMBER - KROGER PHARMACY 903

Laboratory Demographics

  • CLIA Code: 15D1034680
  • Facility Name: KROGER PHARMACY 903
  • Facility Address: 1217 E IRELAND RD
    SOUTH BEND, IN
    ZIP 46614
  • Facility Phone: 574 291-0740
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: THOMAS MATHSON
  • NPI Number: 1588737100
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 15D1034680
LAB Type Pharmacy
Facility Name KROGER PHARMACY 903
Street 1217 E IRELAND RD
City SOUTH BEND
State IN
ZIP 46614
Phone 574 291-0740
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/9/2024
Certificate Expiration Date 12/8/2026
Facility Type Pharmacy
Lab Director THOMAS MATHSON

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