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AVITA ONTARIO PHARMACY
CAH361325-14 GALION COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
GALION COMMUNITY HOSPITAL
Subdivision Name
Rural Health Clinic - State Route 598 (RHC 1200) - Physician Practice
Type
Critical Access Hospital
340B ID
CAH361325-14
Entity Address
1200 State Route 598
Galion, OH 44833
Medicare Provider Number
361325
Outpatient Facility Provider Number
363403
Participating Start Date
4/1/2020
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
1/23/2020
Contract Begin Date
4/1/2020
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
1/15/2020
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