25D1023336 CLIA NUMBER - KROGER PHARMACY #464

Laboratory Demographics

  • CLIA Code: 25D1023336
  • Facility Name: KROGER PHARMACY #464
  • Facility Address: 3095 GOODMAN ROAD
    SOUTHAVEN, MS
    ZIP 38672
  • Facility Phone: 662 890-9105
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: CYNTHIA B. FISHER
  • NPI Number: 1386678167
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 25D1023336
LAB Type Pharmacy
Facility Name KROGER PHARMACY #464
Street 3095 GOODMAN ROAD
City SOUTHAVEN
State MS
ZIP 38672
Phone 662 890-9105
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/15/2024
Certificate Expiration Date 3/14/2026
Facility Type Pharmacy
Lab Director CYNTHIA B. FISHER

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