Provider Demographics
NPI:1609247683
Name:MORATAYA, GLENN BRYAN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:BRYAN
Last Name:MORATAYA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 CARLETON AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-5109
Mailing Address - Country:US
Mailing Address - Phone:626-222-6687
Mailing Address - Fax:
Practice Address - Street 1:5000 SAN BERNARDINO ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2326
Practice Address - Country:US
Practice Address - Phone:909-625-8371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH72409183500000X, 1835G0303X, 1835P0018X, 1835P1200X, 1835P1300X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care