Provider Demographics
NPI:1013230622
Name:MCEWEN, LORI RAE (RPH, MBA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:RAE
Last Name:MCEWEN
Suffix:
Gender:F
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 LAKE FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-2931
Mailing Address - Country:US
Mailing Address - Phone:724-824-8300
Mailing Address - Fax:724-588-3742
Practice Address - Street 1:16086 CONNEAUT LAKE ROAD
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:814-724-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-25675183500000X
PARP030138L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007455310015Medicaid