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Despite a thousand years of history in Nepalese medicinal plant trade to China, there has not been much comprehensive studies that overview the trade from past to present. This study explores the history of the Nepalese medicinal plant trade with China, providing a complete overview of the species involved, their conservation status, and demand drivers. Accordingly, in this study the literature on Sino-Nepal trade relations is reviewed, government reports and data tracked, and interviews conducted with forest officials and exporters trading with China. This study documents 54 medicinal plant species previously (or currently) traded with China. The value of medicinal plants traded with China is worth more than three times as much as the volume exported in percentage terms. Twenty-six species fall into national or international conservation categories. The industrialization of Tibetan medicine, access to modern transportation for the supply of medicinal ingredients and products, globalization of the medicinal plant market, and high per capita income of Chinese people have resulted in consumer behavior shifting toward herbal medication and an increase in the Nepalese medicinal plant trade with China. To mitigate the depletion of resources caused by high demand of medicinal plants, immediate action is required to address trade sustainability as well as prioritize local traditional knowledge and resource-based industry for the substantial socio-cultural and economic benefits both to the local people and nation.