Provider Demographics
NPI:1982945556
Name:AXLINE'S INC.
Entity Type:Organization
Organization Name:AXLINE'S INC.
Other - Org Name:AXLINE PHARMACY (05)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
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:309-828-6970
Practice Address - Street 1:1210 TOWANDA AVE STE 11
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7415
Practice Address - Country:US
Practice Address - Phone:309-828-6767
Practice Address - Fax:309-828-6970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540181663336C0003X, 3336C0003X, 3336C0003X
3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1487772OtherNCPDP
2138618OtherPK
2138618OtherPK