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AVITA HEALTH SYSTEM
CAH361316-07 BUCYRUS COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BUCYRUS COMMUNITY HOSPITAL
Subdivision Name
Provider Based Clinic - Hill Street (PBC 130) - Pain Clinic
Type
Critical Access Hospital
340B ID
CAH361316-07
Entity Address
130 Hill Street
Bucyrus, OH 44820
Medicare Provider Number
361316
Outpatient Facility Provider Number
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
AVITA HEALTH SYSTEM
Pharmacy Address
D.B.A AVITA CRESTLINE PHARMACY
385 N SELTZER ST UNIT 4
CRESTLINE, OH 44827
Pharmacy Comments
Contract Details
Approval Date
4/22/2025
Contract Begin Date
7/1/2025
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
4/15/2025
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