=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982945556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXLINE'S INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2013
-----------------------------------------------------
Last Update Date | 03/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 TOWANDA AVE STE 11
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-7415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-828-6767
-----------------------------------------------------
Fax | 309-828-6970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1087
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61702-1087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-828-6767
-----------------------------------------------------
Fax | 309-828-6970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | TROY WILLIAMS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 309-828-6767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054018166
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------