Provider Demographics
NPI:1134460009
Name:OTAKE, GLENN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:OTAKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8523 BRAUN KNL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5584
Mailing Address - Country:US
Mailing Address - Phone:210-844-9426
Mailing Address - Fax:
Practice Address - Street 1:9238 N LOOP 1604 W
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2577
Practice Address - Country:US
Practice Address - Phone:210-682-3419
Practice Address - Fax:210-521-5184
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist