Provider Demographics
NPI:1801850276
Name:AXLINE'S INC.
Entity Type:Organization
Organization Name:AXLINE'S INC.
Other - Org Name:AXLINE PHARMACY (01)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-734-5196
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:309-734-5196
Mailing Address - Fax:309-734-5356
Practice Address - Street 1:220 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1741
Practice Address - Country:US
Practice Address - Phone:309-734-5196
Practice Address - Fax:309-734-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000106332B00000X
IL540074203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1409665OtherNCPDP NUMBER
1409665OtherNCPDP NUMBER
IL=========001Medicaid