In recent years the pharmaceutical industry has been accused of prioritising profits from patents at the expense of the wellbeing of patients. Many argue that this transition reflects the full-scale financialization of the industry, whereby an increasing focus on shareholder value and financial performance has resulted in cost-cutting, outsourcing and novel forms of competition based on securing new patents and intellectual property rights through mergers and acquisitions (M&As). The aim of this article is to explore the variegated financialization of the pharmaceutical industry through the analysis of M&A data. Acknowledging M&As as a key tenet of pharmaceutical financialization and drawing from a sample of 1805 deals between 2001–2020, we reveal an uneven geography of acquirers and targets across the global, national and city scales. While we uncover a global rise in the value and volume of M&A deals, this activity is concentrated across a limited geography, with the US the largest market by value and China the largest by volume. Analysing these two countries in depth reveals the importance of institutional and regulatory conditions in not only shaping the implementation of M&As but fundamentally constituting the nature, causes and effects of financialization. These findings allow us to develop a relational conceptualisation of financialization which adds novelty to geographical debates around its uneven causes, processes and outcomes.