Provider Demographics
NPI:1386717502
Name:MOORE FAMILY STORES INC.
Entity type:Organization
Organization Name:MOORE FAMILY STORES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-362-6226
Mailing Address - Street 1:115 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2344
Mailing Address - Country:US
Mailing Address - Phone:217-342-2185
Mailing Address - Fax:217-342-7069
Practice Address - Street 1:115 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2344
Practice Address - Country:US
Practice Address - Phone:217-342-2185
Practice Address - Fax:217-342-7069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540203283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054016709OtherSTATE PHARMACY LICENSE
1386717502OtherNPI
1463708OtherNCPDP
IL16103882OtherSTATE TAX ID
FJ1544370OtherDEA REGISTRATION
FJ1544370OtherDEA REGISTRATION
FJ1544370OtherDEA REGISTRATION