Provider Demographics
NPI:1558714972
Name:GREGG, DYLON (PHARMD)
Entity Type:Individual
Prefix:
First Name:DYLON
Middle Name:
Last Name:GREGG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E LASALLE AVE
Mailing Address - Street 2:APT 325-L
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2777
Mailing Address - Country:US
Mailing Address - Phone:765-639-2662
Mailing Address - Fax:
Practice Address - Street 1:102 E HIVELY AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2194
Practice Address - Country:US
Practice Address - Phone:574-522-2197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026701A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist