340B Drug Pricing Program Database
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AVITA HEALTH SYSTEM
AVITA ONTARIO HOSPITAL
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Covered Entity Details
Entity Name
AVITA ONTARIO HOSPITAL
Subdivision Name
Provider Based Clinic - Richland Mall (PBC 600 - 205)
Type
Disproportionate Share Hospital
340B ID
Entity Address
600 Richland Mall, Ste 205
Ontario, OH 44906
Medicare Provider Number
360365
Outpatient Facility Provider Number
Participating Start Date
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
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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