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AVITA HEALTH SYSTEM
DSH360365 AVITA ONTARIO HOSPITAL
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Covered Entity Details
Entity Name
AVITA ONTARIO HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360365
Entity Address
715 RICHLAND MALL
ONTARIO, OH 44906
Medicare Provider Number
360365
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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