25D2035642 CLIA NUMBER - WALGREENS #04455

Laboratory Demographics

  • CLIA Code: 25D2035642
  • Facility Name: WALGREENS #04455
  • Facility Address: 35 STATELINE RD W
    SOUTHAVEN, MS
    ZIP 38671
  • Facility Phone: 601 342-2906
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: AMANDA B. STEVENS
  • NPI Number: 1457523581
  • Taxonomy: 333600000X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 25D2035642
LAB Type Pharmacy
Facility Name WALGREENS #04455
Street 35 STATELINE RD W
City SOUTHAVEN
State MS
ZIP 38671
Phone 601 342-2906
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/31/2025
Certificate Expiration Date 3/30/2027
Facility Type Pharmacy
Lab Director AMANDA B. STEVENS

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