1285787226 NPI number — AXLINE'S INC.

Table of content: (NPI 1285787226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285787226 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:
Provider Other Organization Name Type Code:
6
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:
1285787226
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:
309-828-6767
Provider Business Mailing Address Fax Number:
309-828-6970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUSHNELL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61422-1353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-772-3155
Provider Business Practice Location Address Fax Number:
309-772-3156
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
TROY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER,RPH,AO
Authorized Official Telephone Number:
309-828-6767

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054018760 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1413385 . This is a "NCPDP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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