The study aimed to determine the hazardous health effects of pesticides exposure in the factory workers by measuring plasma cholinesterase (PChE), pesticides residues, and renal and hepatic biochemical markers. In addition, we also assessed the knowledge, attitudes, and safety practices adopted by the industrial workers. The study was conducted in three different sizes of factories located in Lahore (large), Multan (medium), and Karachi (small) in Pakistan. Total 238 adult males consisting of 184 pesticide industrial workers (exposed group) from large-sized (67), medium-sized (61), small-sized (56) industrial formulation factories, and 54 controls (unexposed) were included in the study. All the participants were male of aged 18 to 58 years. PChE levels were estimated by Ellmann's method. Plasma pesticides residue analysis was performed by using reverse phase C-18 on high-performance liquid chromatograph and GC with NPD detector. Plasma alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine, urea, and gamma glutamyltransferase (GGT) were measured on Selectra E auto analyzer. Plasma and C-reactive protein was analyzed by Immulite 1000. The results revealed a significant decrease in plasma post exposure PChE levels (<30%) as compared to baseline in the workers of small (29%) and medium (8%) industrial units (p < 0.001). Plasma cypermethrin, endosulfan, imidacloprid, thiodicarb, carbofuran, and methamidophos levels were found to be higher than allowable daily intake. Serum AST, ALT, creatinine GGT, malondialdehyde, total antioxidant, and CRP were significantly raised among the workers of small and medium pesticide formulation factories as compared to large industrial unit and controls (p < 0.001). The study demonstrated that unsafe practices among small- and medium-sized pesticides industrial workers cause significant increase in pesticide exposure, oxidative stress, and derangement of hepatic and renal function.