21D2290555 CLIA NUMBER - WALGREENS #17205

Laboratory Demographics

  • CLIA Code: 21D2290555
  • Facility Name: WALGREENS #17205
  • Facility Address: 1030 WEST 41ST STREET SUITE E
    BALTIMORE, MD
    ZIP 21211
  • Facility Phone: 410 235-0002
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: DEREK ETUBE
  • NPI Number: 1740704220
  • Taxonomy: 333600000X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 21D2290555
LAB Type Pharmacy
Facility Name WALGREENS #17205
Street 1030 WEST 41ST STREET SUITE E
City BALTIMORE
State MD
ZIP 21211
Phone 410 235-0002
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/27/2025
Certificate Expiration Date 9/26/2027
Facility Type Pharmacy
Lab Director DEREK ETUBE

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