Contract Pharmacy Details

AVITA HEALTH SYSTEM
DSH360365D AVITA ONTARIO HOSPITAL

Covered Entity Details

Entity Name

AVITA ONTARIO HOSPITAL

Subdivision Name

Provider Based Clinic - Richland Mall (PBC 600 - 205) - Neurology Provider Office

Type

Disproportionate Share Hospital

340B ID

DSH360365D

Entity Address

600 Richland Mall, Ste 205
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

340B Drug Pricing Program Database