Organization
AXLINE ADVANCED
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DANIEL PAUL DUNCAN (OPERATIONS MANAGER)
(309) 828-6979
Entity
Organization
Contact information
Practice address
1210 TOWANDA AVE, UNIT 10, BLOOMINGTON, IL 61701-3454
(309) 828-6979
(309) 828-6977
Mailing address
1210 TOWANDA AVE STE 10, PO BOX 1087, BLOOMINGTON, IL 61701-7415
(309) 828-6979
(309) 828-6977
Taxonomy
Speciality
Code
Description
License number
State
3336L0003X
Long Term Care Pharmacy
Primary
054-017559
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
054-017559
ILLINOIS LICENSE
IL
01
—
1484978
NCPDP
IL
Enumeration date
10/22/2010
Last updated
03/16/2022
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