Provider Demographics
NPI:1215237359
Name:AXLINE ADVANCED
Entity type:Organization
Organization Name:AXLINE ADVANCED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-6979
Mailing Address - Street 1:1210 TOWANDA AVE STE 10
Mailing Address - Street 2:PO BOX 1087
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7415
Mailing Address - Country:US
Mailing Address - Phone:309-828-6979
Mailing Address - Fax:309-828-6977
Practice Address - Street 1:1210 TOWANDA AVE
Practice Address - Street 2:UNIT 10
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3454
Practice Address - Country:US
Practice Address - Phone:309-828-6979
Practice Address - Fax:309-828-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0175593336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-017559OtherILLINOIS LICENSE
IL1484978OtherNCPDP