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AVITA HEALTH SYSTEM
DSH360365A AVITA ONTARIO HOSPITAL
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Covered Entity Details
Entity Name
AVITA ONTARIO HOSPITAL
Subdivision Name
Provider Based Clinic - Richland Mall (PBC 600 - 203) - Internal Med
Type
Disproportionate Share Hospital
340B ID
DSH360365A
Entity Address
600 Richland Mall, Ste 203
Ontario, OH 44906
Medicare Provider Number
360365
Outpatient Facility Provider Number
Participating Start Date
7/1/2024
Last Recertification Date
8/28/2024
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
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
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
4/15/2025
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