25D2125984 CLIA NUMBER - SAM'S PHARMACY 10-4740

Laboratory Demographics

  • CLIA Code: 25D2125984
  • Facility Name: SAM'S PHARMACY 10-4740
  • Facility Address: 465 GOODMAN RD E
    SOUTHAVEN, MS
    ZIP 38671
  • Facility Phone: 662 349-3740
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: NATHAN RUCKER
  • NPI Number: 1528085941
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 25D2125984
LAB Type Pharmacy
Facility Name SAM'S PHARMACY 10-4740
Street 465 GOODMAN RD E
City SOUTHAVEN
State MS
ZIP 38671
Phone 662 349-3740
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/16/2025
Certificate Expiration Date 2/15/2027
Facility Type Pharmacy
Lab Director NATHAN RUCKER

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