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AVITA ONTARIO PHARMACY
CAH361325-13 GALION COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
GALION COMMUNITY HOSPITAL
Subdivision Name
Provider Based Clinic - (PBC 865) - Pediatric Therapy
Type
Critical Access Hospital
340B ID
CAH361325-13
Entity Address
865 Harding Way West
Galion, OH 44833
Medicare Provider Number
361325
Outpatient Facility Provider Number
Participating Start Date
10/1/2018
Last Recertification Date
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
AVITA ONTARIO PHARMACY
Pharmacy Address
600 RICHLAND MALL STE 202A
MANSFIELD, OH 44906
Pharmacy Comments
Contract Details
Approval Date
7/19/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
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
7/11/2018
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