||This article traces patterns of continuity and transformation shaping Sowa Rigpa (Tibetan medicine) pharmacy in contemporary Ladakh, Himalayan India. It examines interlinked changes in the way medicines are being formulated, manufactured, assessed, and positioned in relation to wider social, economic, and political processes. The focus is on two practitioners who share a great deal, including medical lineage, training, and ritual connection, but whose pharmacy practices diverge in several crucial ways. The article compares the institutional contexts within which they make medicine, examines their interactions with technology and labor, and considers the dynamics of authority, power, and agency influencing their activities. Engaging the concept of “currents of tradition” and elements of assemblage theory, the author shows how changes in pharmacy practice relate to changes in the values assigned to Tibetan medicines, in their distribution patterns, and in the effects they have in the social world. In the period of flux and accelerating medical modernization that has followed the official recognition of Sowa Rigpa in 2010, pharmaceutical practice appears as an important field in which traditional medicine is at once expressed, maintained, and transformed.