Healthcare Provider Details

I. General information

NPI: 1609247683
Provider Name (Legal Business Name): GLENN BRYAN MORATAYA PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SAN BERNARDINO ST
MONTCLAIR CA
91763-2326
US

IV. Provider business mailing address

479 CARLETON AVE
CLAREMONT CA
91711-5109
US

V. Phone/Fax

Practice location:
  • Phone: 909-625-8371
  • Fax:
Mailing address:
  • Phone: 626-222-6687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH72409
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRPH72409
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH72409
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH72409
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberRPH72409
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRPH72409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: