Provider Demographics
NPI:1376593483
Name:AXLINE'S INC.
Entity Type:Organization
Organization Name:AXLINE'S INC.
Other - Org Name:FLANAGAN HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-6767
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-1087
Mailing Address - Country:US
Mailing Address - Phone:309-828-6767
Mailing Address - Fax:309-828-6978
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FLANAGAN
Practice Address - State:IL
Practice Address - Zip Code:61740-7536
Practice Address - Country:US
Practice Address - Phone:815-796-2274
Practice Address - Fax:815-796-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0181653336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1453668OtherNCPDP