Covered Entity Details

DSH360365E AVITA ONTARIO HOSPITAL (Active) - information as of 6/19/2025 11:46:57 PM

Main Details

Name

AVITA ONTARIO HOSPITAL

Subdivision Name

Provider Based Clinic - Richland Mall (PBC 600 - 205) - Endocrinology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH360365E

Medicare Provider Number

360365

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/25/2024

Last Recertification Date

Contacts

Authorizing Official

Avita Health System
ERIC DRAIME, CHIEF FINANCIAL OFFICER
(419) 468-0501

Primary Contact

Avita Health System
Christina Barnes, Director of Pharmacy
(419) 468-0541

Addresses

Street Address

600 Richland Mall
205
Ontario, OH 44906

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
OH	0217883	1689822827,1790131050

Shipping Addresses

Shipping Address 1

Bucyrus Community Hospital
629 North Sandusky Avenue
Bucyrus, OH 44820

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	AVITA HEALTH SYSTEM	D.B.A AVITA CRESTLINE PHARMACY	385 N SELTZER ST UNIT 4	CRESTLINE	OH	44827	04/15/2025	07/01/2025			04/15/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH360365A	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 203) - Internal Med	600 Richland Mall, Ste 203	Ontario	OH	Active
DSH360365B	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 203) - Family Medicine	600 Richland Mall, STE 203	Ontario	OH	Active
DSH360365C	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 204) - Pediatric Provider Office	600 Richland Mall, Ste 204	Ontario	OH	Active
DSH360365D	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 205) - Neurology Provider Office	600 Richland Mall, Ste 205	Ontario	OH	Active
DSH360365E	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 205) - Endocrinology	600 Richland Mall	Ontario	OH	Active
DSH360365F	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 205) - Plastic Surgery	600 Richland Mall	Ontario	OH	Active
DSH360365G	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 201) - Pain Clinic	600 Richland Mall	Ontario	OH	Active
DSH360365H	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 202) - Medication Management	600 Richland Mall	Ontario	OH	Active
DSH360365J	Child	DSH	AVITA ONTARIO HOSPITAL	Provider Based Clinic - Richland Mall (PBC 600 - 205) - Pulmonary	600 Richland Mall, Ste 205	Ontario	OH	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		DRAIME, ERIC CHIEF FINANCIAL OFFICER Avita Health System 4194680501	8/25/2024 12:40 PM
Details	340B ID	Update	New Registration		DSH360365E	8/25/2024 12:40 PM
Details	Entity Subname	Update	New Registration	Provider Based Clinic - Richland Mall (PBC 600 - 205)	Provider Based Clinic - Richland Mall (PBC 600 - 205) - Endocrinology	8/25/2024 12:40 PM
Dates	Participating Approval Date	Update	New Registration		8/25/2024 12:40:31 PM	8/25/2024 12:40 PM
Details	State	Update	New Registration	Pending	Approved	8/25/2024 12:40 PM
Dates	Signed By Date	Update	New Registration		7/11/2024 1:33:45 PM	8/25/2024 12:40 PM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/25/2024 12:40 PM
Addresses	Main Address	Insert	New Registration		600 Richland Mall 205 Ontario, OH 44906	7/11/2024 1:33 PM
Addresses	Shipping Address	Insert	New Registration		Bucyrus Community Hospital 629 North Sandusky Avenue Bucyrus, OH 44820	7/11/2024 1:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 1:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0217883	7/11/2024 1:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/11/2024 1:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1689822827	7/11/2024 1:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/11/2024 1:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1790131050	7/11/2024 1:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/11/2024 1:33 PM
Contacts	Primary Contact	Insert	New Registration		Barnes, Christina Director of Pharmacy Avita Health System 4194680541	7/11/2024 1:33 PM
Contacts	Authorizing Official	Insert	New Registration		DRAIME, ERIC CHIEF FINANCIAL OFFICER Avita Health System 4194680501	7/11/2024 1:33 PM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 1:33 PM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 1:33 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 1:33 PM
Details	Grant Number	Insert	New Registration			7/11/2024 1:33 PM
Details	340B ID	Insert	New Registration			7/11/2024 1:33 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 1:33 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 1:33 PM
Details	Medicare Provider Number	Insert	New Registration		360365	7/11/2024 1:33 PM
Details	Entity Name	Insert	New Registration		AVITA ONTARIO HOSPITAL	7/11/2024 1:33 PM
Details	NOFO Number	Insert	New Registration			7/11/2024 1:33 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2024 1:33 PM
Details	Entity Subname	Insert	New Registration		Provider Based Clinic - Richland Mall (PBC 600 - 205)	7/11/2024 1:33 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 1:33 PM
Details	State	Insert	New Registration		Pending	7/11/2024 1:33 PM
Dates	Registration Date	Insert	New Registration		7/11/2024 1:33:41 PM	7/11/2024 1:33 PM
Dates	Signed By Date	Insert	New Registration			7/11/2024 1:33 PM
Dates	Start Date	Insert	New Registration			7/11/2024 1:33 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 1:33 PM
Terminations	Termination Date	Insert	New Registration			7/11/2024 1:33 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 1:33 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 1:33 PM