Contract Pharmacy Details

AVITA ONTARIO PHARMACY
CAH361325-04 GALION COMMUNITY HOSPITAL

Covered Entity Details

Entity Name

GALION COMMUNITY HOSPITAL

Subdivision Name

Provider Based Clinic - Hosford Road (PBC 955)

Type

Critical Access Hospital

340B ID

CAH361325-04

Entity Address

955 Hosford Rd
Galion, OH 44833

Medicare Provider Number

361325

Outpatient Facility Provider Number

Participating Start Date

10/1/2013

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

AVITA ONTARIO PHARMACY

Pharmacy Address

600 RICHLAND MALL STE 202A
MANSFIELD, OH 44906

Pharmacy Comments

Contract Details

Approval Date

7/10/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2022
Ownership change

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

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

Signed By Date

7/10/2018

340B Drug Pricing Program Database