Provider Demographics
NPI:1326535303
Name:DAYTON GASTROENTEROLOGY LLC
Entity Type:Organization
Organization Name:DAYTON GASTROENTEROLOGY LLC
Other - Org Name:DG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AO/ DIRECTOR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:CATHLEEN
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-737-4665
Mailing Address - Street 1:1620 W NORTHWEST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3119
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-720-1039
Practice Address - Street 1:75 SYLVANIA DR
Practice Address - Street 2:SUITE B
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3237
Practice Address - Country:US
Practice Address - Phone:844-926-8244
Practice Address - Fax:932-320-7518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
OH0228592503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177029OtherPK