Healthcare Provider Details

I. General information

NPI: 1811128440
Provider Name (Legal Business Name): SOMETHING DIFFERENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 E ROOSEVELT AVE
GRANTS NM
87020-2113
US

IV. Provider business mailing address

741 E ROOSEVELT AVE
GRANTS NM
87020-2113
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-7555
  • Fax:
Mailing address:
  • Phone: 505-287-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH00003102
License Number StateNM

VIII. Authorized Official

Name: CYDNI J. REYNOLDS
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 505-287-7555