25D1021501 CLIA NUMBER - KROGER PHARMACY #404

Laboratory Demographics

  • CLIA Code: 25D1021501
  • Facility Name: KROGER PHARMACY #404
  • Facility Address: 465 STATELINE ROAD WEST
    SOUTHAVEN, MS
    ZIP 38671
  • Facility Phone: 662 393-3426
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: CYNTHIA B. FISHER
  • NPI Number: 1275567042
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 25D1021501
LAB Type Pharmacy
Facility Name KROGER PHARMACY #404
Street 465 STATELINE ROAD WEST
City SOUTHAVEN
State MS
ZIP 38671
Phone 662 393-3426
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/23/2024
Certificate Expiration Date 1/22/2026
Facility Type Pharmacy
Lab Director CYNTHIA B. FISHER

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