52D2258302 CLIA NUMBER - SAM'S CLUB PHARMACY 10-8149

Laboratory Demographics

  • CLIA Code: 52D2258302
  • Facility Name: SAM'S CLUB PHARMACY 10-8149
  • Facility Address: 2470 W MASON ST
    GREEN BAY, WI
    ZIP 54303
  • Facility Phone: 432 253-7669
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: SCOTT FORTNEY
  • NPI Number: 1972919520
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 52D2258302
LAB Type Pharmacy
Facility Name SAM'S CLUB PHARMACY 10-8149
Street 2470 W MASON ST
City GREEN BAY
State WI
ZIP 54303
Phone 432 253-7669
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/20/2024
Certificate Expiration Date 4/19/2026
Facility Type Pharmacy
Lab Director SCOTT FORTNEY

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