45D2125484 CLIA NUMBER - SAM'S CLUB PHARMACY 10-4795

Laboratory Demographics

  • CLIA Code: 45D2125484
  • Facility Name: SAM'S CLUB PHARMACY 10-4795
  • Facility Address: 1701 W STATE HIGHWAY 114
    GRAPEVINE, TX
    ZIP 76051
  • Facility Phone: 682 271-5221
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: MATHEW PRASAD
  • NPI Number: 1114011319
  • Taxonomy: 332H00000X - Eyewear Supplier

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CLIA Record

Field Name Field Value
CLIA Number 45D2125484
LAB Type Pharmacy
Facility Name SAM'S CLUB PHARMACY 10-4795
Street 1701 W STATE HIGHWAY 114
City GRAPEVINE
State TX
ZIP 76051
Phone 682 271-5221
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/10/2024
Certificate Expiration Date 6/9/2026
Facility Type Pharmacy
Lab Director MATHEW PRASAD

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