Healthcare Provider Details

I. General information

NPI: 1386717502
Provider Name (Legal Business Name): MOORE FAMILY STORES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 03/07/2023
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W JEFFERSON AVE
EFFINGHAM IL
62401-2344
US

IV. Provider business mailing address

115 W JEFFERSON AVE
EFFINGHAM IL
62401-2344
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-2185
  • Fax: 217-342-7069
Mailing address:
  • Phone: 217-342-2185
  • Fax: 217-342-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054020328
License Number StateIL

VIII. Authorized Official

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