=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538166137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE FAMILY STORES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 STALEY AVE
-----------------------------------------------------
City | CASEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62420-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-932-4004
-----------------------------------------------------
Fax | 217-609-6065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2245 W MOUND RD
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-9367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-362-6226
-----------------------------------------------------
Fax | 217-362-6241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | TRENT J MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-362-6226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054020331
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------