Provider Demographics
NPI:1275819039
Name:OTTERMAN, GLENN E JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:E
Last Name:OTTERMAN
Suffix:JR
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 1:5958 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 W 39TH AVE
Practice Address - Street 2:SAN MATEO MEDICAL CENTER
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4364
Practice Address - Country:US
Practice Address - Phone:650-573-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH31942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist