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AVITA ONTARIO PHARMACY
CAH361316-00 BUCYRUS COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BUCYRUS COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361316-00
Entity Address
629 N SANDUSKY AVENUE
BUCYRUS, OH 44820
Medicare Provider Number
361316
Participating Start Date
1/1/2011
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
Contacts
Covered Entity Signing Official
Eric Draime, CFO
(419) 468-0501
Contract Pharmacy Representative
Avita Health System
Christina Barnes, Director of Pharmacy
(419) 468-0541
Signed By Date
7/10/2018
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