Healthcare Provider Details

I. General information

NPI: 1538166137
Provider Name (Legal Business Name): MOORE FAMILY STORES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STALEY AVE
CASEY IL
62420-1458
US

IV. Provider business mailing address

2245 W MOUND RD
DECATUR IL
62526-9367
US

V. Phone/Fax

Practice location:
  • Phone: 217-932-4004
  • Fax: 217-609-6065
Mailing address:
  • Phone: 217-362-6226
  • Fax: 217-362-6241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054020331
License Number StateIL

VIII. Authorized Official

Name: TRENT J MOORE
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 217-362-6226