15D1077179 CLIA NUMBER - KROGER PHARMACY 963

Laboratory Demographics

  • CLIA Code: 15D1077179
  • Facility Name: KROGER PHARMACY 963
  • Facility Address: 2001 N MICHIGAN
    PLYMOUTH, IN
    ZIP 46563
  • Facility Phone: 574 936-1980
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: MICHELLE M. LYLE
  • NPI Number: 1104999622
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 15D1077179
LAB Type Pharmacy
Facility Name KROGER PHARMACY 963
Street 2001 N MICHIGAN
City PLYMOUTH
State IN
ZIP 46563
Phone 574 936-1980
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/4/2023
Certificate Expiration Date 12/3/2025
Facility Type Pharmacy
Lab Director MICHELLE M. LYLE

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