MEDICARE: MOORE FAMILY STORES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	054020330	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2016686	OTHER		PK

General Provider Information

NPI Number	:	1326061284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOORE FAMILY STORES INC.

Provider Business Mailing Address
First Line	:	2245 W MOUND RD
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62526-9367
Country	:	US
Telephone Number	:	217-362-6226
Fax Number	:	217-362-6241

Provider Business Practice Location Address
First Line	:	104 COURT HOUSE SQ
Second Line	:
City	:	TOLEDO
State	:	IL
Zip	:	62468
Country	:	US
Telephone Number	:	217-849-2666
Fax Number	:	217-849-2015

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	TRENT MOORE
Credential	:
Telephone Number	:	217-362-6226

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	06/20/2022

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Directions to “MOORE FAMILY STORES INC. ” Practice Location

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