1407286941 NPI number — AXLINE'S INC.

Table of content: (NPI 1407286941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407286941 NPI number — AXLINE'S INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AXLINE'S INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AXLINE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407286941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1087
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61702-1087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-828-6979
Provider Business Mailing Address Fax Number:
309-828-6978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 S. MCCOY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-339-2323
Provider Business Practice Location Address Fax Number:
815-339-2324
Provider Enumeration Date:
11/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
TROY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
309-660-5939

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1488495 . This is a "NCPDP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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